AGES 2007

AGES 2007XVII ANNUAL SCIENTIFIC MEETINGAustralianGynaecologicalEndoscopySociety LtdPROGRAMInternational Guest SpeakersProfessor Javier Magrina USADr Alfred Cutner UK17 – 19 May 2007THE WESTIN SYDNEYAUSTRALIAPlatinum sponsor of AGESMajor Sponsor of AGES

The AGES grafefullyacknowledges the support of thefollowing companiesPlatinum Sponsor of AGESMajor Sponsor of AGESMajor Sponsors of AGES 2007ExhibitorsCytycAmerican Medical SystemsApplied MedicalB BraunFisher & PaykelGyrus ACMIN StenningOlympusSydney IVFAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGBardBoston ScientificCook AustraliaDevice TechnologiesEndocorpExperienGytechInSight OceaniaMedfinNoall & CoSydmed AustraliaSymbion Laverty Pathology

AGES 2007riskConference CommitteeAustralian FacultyAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGAssoc Professor Alan LamDr Gregory CarioAssoc Professor Chris BennessAssoc Professor George CondousDr Michael CooperDr Michael McEvoyDr Harry MerkurDr Alastair MorrisDr Robert O’SheaDr Geoffrey ReidDr Sony SinghDr Jim TsaltasAGES BoardDr Robert O’SheaAssoc Professor Alan LamDr Jim TsaltasDr Geoffrey ReidDr Greg CarioDr Jenny CookProfessor David HealyDr Krish KarthigasuDr Chris MaherDr Anusch YazdaniAGES Secretariat –Conference OrganiserMichele Bender, DirectorConference ConnectionPhone: +61 2 9967 2928Fax: +61 2 9967 2627Mobile: +61 4 1111 0464E-mail: conferences@ages.com.auAddress: 282 Edinburgh RoadCASTLECRAG NSW 2068New South WalesChairmanNew South WalesCo-ChairmanNew South WalesNew South WalesNew South WalesSouth AustraliaNew South WalesNew South WalesSouth AustraliaNew South WalesNew South WalesVictoriaPresidentVice PresidentHon SecretaryTreasurerInternational FacultyProfessor Javier MagrinaDr Alfred CutnerUSAUKAssoc Professor Alan LamDr Gregory CarioDr Jason AbbottDr John AllanDr Kenneth AtkinsonAssoc Professor Chris BennessDr Mark CarltonAssoc Professor George CondousDr Jenny CookDr Michael CooperAssoc Professor Peter DietzDr Justin EvansDr Robert FordDr Stephen FordProfessor David HealyMs Michelle HignettDr Krish KarthigasuDr Alan KayeDr Megan KeaneyDr Vince LamaroMr Leonard Levy SCAssoc Professor Chris MaherAssoc Professor Peter MaherDr Michael McEvoyDr Harry MerkurDr David MolloyDr Robert O’SheaDr Geoffrey ReidDr David RosenProfessor Allan SpigelmanAssoc Professor John SvigosDr Hugh TorodeDr Jim TsaltasAssoc Professor Thierry VancaillieDr Nesrin VarolDr Justin VassAssoc Professor Merrilyn WaltonDr Anusch YazdaniIRM PointsNew South WalesNew South WalesNew South WalesQueenslandNew South WalesNew South WalesNew South WalesNew South WalesSouth AustraliaNew South WalesNew South WalesNew South WalesNew South WalesNew South WalesVictoriaNew South WalesWestern AustraliaNew South WalesNew South WalesNew South WalesNew South WalesQueenslandVictoriaSouth AustraliaNew South WalesQueenslandSouth AustraliaNew South WalesNew South WalesNew South WalesSouth AustraliaNew South WalesVictoriaNew South WalesNew South WalesNew South WalesNew South WalesQueenslandMembership of AGESMembership application forms are available from the AGES websiteor from: the AGES Secretariat,282 Edinburgh Road, CASTLECRAG NSW 2068.This meeting has been approved for 4 Interactive Risk Managementpoints for MIGA or MDASA.2

PROGRAMX VII ANNUALSCIENTIFICMEETINGriskmanagementingynaecology andendoscopic surgeryTHURSDAY 17 MAY 2007THE BALLROOMTHE WESTIN SYDNEY0700-0800 Conference Registration0800-0810 Conference Opening and WelcomeAGES PresidentConference Chairman0810-0830 SESSION I – PR&CRMSponsored by Stryker0810-0825 AGES Risk Management SurveyTransponder session0825-0830 PR&CRM Pre-questionnaires0830-1015 SESSION II – Risk ManagementChairs: R O’Shea, D HealySponsored by Stryker0830-0850 Complications in gynaecological /endoscopic surgeryR O’SheaA LamM McEvoyJ CookJ Magrina1330-1500 SESSION IV – AnatomyChair: C Maher1330-1350 Pelvic anatomy – the essentials for safer surgeryJ Magrina1350-1500 Live Surgery – Mater HospitalSurgeons: A Lam, R FordModerators: J Tsaltas, G CarioCase: Frozen Pelvis or Entrapped Ovary1500-1530 Afternoon Tea and Trade exhibition1530-1700 SESSION V - Free CommunicationsFREE COMMUNICATIONS 1Chairs: G Cario, J Tsaltas Ballroom 3LAPARASCOPIC HYSTERECTOMY1530-1540 Laparoscopic hysterectomy – the impact of bodymass index (BMI) and outcomesSoo S, Wang L, Merkur H1540-1550 A review of laparoscopic hysterectomycomplications in the presence of increasinguterine weightSoo S, Mohan R, Wilson M, Merkur H0850-0910 Emerging technologies and techniques –introduction into clinical practiceA Spigelman0910-0930 Risk Management – principles, practices,processesM Keaney, UMP0930-0950 Incorporating Risk Management into practiceM McEvoy0950-1015 Panel discussion1550-1600 Total laparoscopic hysterectomy: use of5mm ligatureTsaltas J, Lawrence A, Najjar H, Tan J1600-1610 Laparoscopic hysterectomy brings new ideas tovaginal hysterectomyEdwards G, Tsaltas J, Najjar H, Tan J, Fitzgerald A1610-1620 Complications of total laparoscopic hysterectomy:The Monash experienceTsaltas J, Lawrence A, Pearce S, Najjar H,Salfinger S, Tan JAGES 2007 XVII ANNUAL SCIENTIFIC MEETING1015-1045 Morning Tea and Trade Exhibition1045-1230 SESSION III – Communication and DocumentationChairs: A Lam, C BennessSponsored by Johnson & Johnson Medical1045-1100 Informed consent – good medicine ordefensive practice?M Keaney, UMP1100-1120 The art and science of good communicationM Walton1120-1140 Guest lecture: Informed Consent – Never Enough!L Levy SC1140-1230 Case presentationsChair: G Reid• Pregnancy after previous tubal ligation• Dyspareunia after pelvic reconstructivesurgery with mesh• Peritonitis following ‘incidental’appendicectomy at hysterectomy1230-1330 Lunch and Trade Exhibition1620-1630 Total laparoscopic hysterectomy pilot phase - RoyalWomen’s Hospital, Melbourne. Assessment of intraand post operative morbidity and financialconsiderations.Sgroi JC, Daly JO, Ang WC, Thomas PC1630-1640 Sydney Women’s Endosurgery Centre statisticsand morbidity 2006Georgiou C, Johnston K, Cario G, Carlton M, Chou D,Cooper M, Reid G and Rosen D1640-1650 Laparoscopic myomectomy with a supracervical“lassoo”Cario G, Georgiou CFREE COMMUNICATIONS 2Chairs: K Kartagasu, D Rosen Ballroom 4UROGYNECOLOGY1530-1540 Laparoscopic mesh repair of a 12cm left glutealhernia in a patient previously managed with Perigeeand posterior IVS plus mesh repair.Georgiou C, Fay L, Lubowski D, Chou D4

PROGRAMX VII ANNUALSCIENTIFICMEETINGriskmanagementingynaecology andendoscopic surgeryAGES 2007 XVII ANNUAL SCIENTIFIC MEETING1330-1500 SESSION VIII – Free CommunicationsFREE COMMUNICATIONS 3Chairs: A Yazdani, G Reid Ballroom 3ENDOSCOPIC PROCEDURES1330-1340 Hysteroscopic resection of caesarean section scarpregnancy – a treatment option for a difficult andincreasingly common clinical situationDeans R, Abbott J, Vancaillie T1340-1350 Laparoscopic excision of retroperitoneal gonad ina patient with complete androgen insensitivity:case report and video presentation.Cameron M, Maher P, Grover P1350-1400 Laparoscopic cervical cerclage: a six step approach– a video presentationSingh SS, Allen LM, Leyland NA, Thomas J,Windrim R, Whittle WL1400-1410 Catheter-guided hysteroscopy: minimizingpatient discomfortDe Decker A, Kingston A, Vancaillie TG1410-1420 Laparoscopic excision of 3cm full thicknessendometriotic bladder nodule with Ligasure.Georgiou C, Aslan P, Chou D1420-1430 Audit of outpatient hysteroscopy andendometrial biopsyGhaly S, Abbott J, De Abreu Lourenco R1430-1440 Asymptomatic extra-uterine translocation of IUD:learning pointsLee L, Ades A, Ang WC1440-1450 Minimally invasive cervical dilatationLee S, Tan JFREE COMMUNICATIONS 4Chairs: R O’Shea, D Chou Ballroom 4GENERAL ENDOSCOPY SESSION1330-1340 Credentialing for advanced laparoscopic proceduresat southern healthVollenhoven B, Tsaltas J, Lawrence A, Shashian T1340-1350 Editing of video/images data in endoscopic surgeryGeorgiou C1350-1400 Bladder dysfunction following gynaecologicallaparoscopic surgeryChetty N, Abbott J1400-1410 A prospective, randomised, double-blind, placebocontrolledtrial of multimodal intra-operativeanalgesia for laparoscopic excision of endometriosisCostello MF , Abbott J , Katz S, Vancaillie T , LenartM , Fawcett S , Walsh R , Wilson S , Lyons S1410-1420 Evaluation of early experience with ambulatorygynaecology clinicSgroi JC, Ang WC, Thomas PC, Healey M1420-1430 Applying education theory to the informed consentprocess using a web-based multimedia application –a prospective, randomized, controlled pilot studyClaydon-Platt D, Cameron M, Maher P, Ong N,Manwaring J, Beischer A1430-1440 The informed consent process in a tertiary publicwomen’s hospital: are we informing our patients(and doctors) and protecting ourselves?Cameron M, Maher P1500-1530 Afternoon Tea and Trade Exhibition1530-1700 SESSION IX – Hysteroscopic SurgeryChairs: H Merkur, J CookSponsored by ConMed Linvatec1530-1550 Endometrial ablation: 2007 best practiceP Maher1550-1610 The dissatisfied patient after endometrial ablationJ Abbott1610-1630 Fluid management: the ins and outs ofhysteroscopic surgery1630-1650 Hysteroscopic tubal occlusion: techniques,outcomes, challenges1650-1700 Panel discussion1715-1815 AGES Annual General Meeting1930-2300 AGES 2007 Gala DinnerCatalina, Rose BayAGES AWARDSThe AGES Awards for 2007 are:John Kerin Awardfor Best Free Communication $500Best Video Presentation $500Best New Technology $500Best Registrar Presentation $500All presentations will be assessed during the Meeting by animpartial judging panel.The Awards will be presented during Session XI of theConference Program.The AGES/Linvatec Travelling Fellowship and theAGES/tyco Travelling Fellowship for 2007 will also bepresented during Session XI of the Conference Program.N VarolD Rosen6

RecognitionInterpretationStrategyKeeping trackAGES2007SATURDAY 19 MAY 2007THE BALLROOMTHE WESTIN SYDNEY0700-0800 Optional Breakfast Session(booking required)Sponsored by CytycHeritage Ballroom – Level 6A video of NovaSure endometrial ablation procedure& post-operative discussionModerators: J Abbott, T Vancaillie.1210-1230 AGES Clinical Research Fund: 2006 GrantsAGES Travelling Fellowships 2007AGES ASM Awards 2007Chairs: A Lam G Cario1230-1330 Lunch and Trade Exhibition1330-1500 SESSION XII –Training, Accreditation and Emerging TechnologiesChairs: J Tsaltas, A CutnerSponsored by Stryker0800-1000 SESSION X – Ensure The System WorksChairs: D Healy, H Torode1330-1350 Are we producing competent surgeons?J Svigos0800-0815 The power and danger of electrosurgeryT Vancaillie0815-0830 Overcoming system failures in the operating roomM Hignett0830-0845 Hospital setting – ‘the good, the bad and the ugly’in endoscopic surgeryG Cario0845-0900 Advanced endoscopic surgery in the NHSA Cutner0900-0915 Corporate-clinician interaction and potential effectson patient careP Dietz1350-1410 The impact of NICE (National Institute ofClinical Excellence) on clinical practice in the UKA Cutner1410-1430 Issues related to the application of meshinto pelvic floor repair1430-1500 Panel discussion1500-1530 Afternoon Tea and Trade Exhibition1530-1700 SESSION XIII –‘What To Do When You are Being Sued’Chairs: M Cooper, K KarthigasuSponsored by StrykerC Maher0915-0930 Panel discussion0930-1000 The Perpetual Daniel O’Connor LectureChair: R O’SheaRobotic endoscopic surgery –advances or gimmicks?1000–1030 Morning Tea and Trade Exhibition1030-1230 SESSION XI – Clinical Judgement –Multidisciplinary ApproachChairs: H Merkur, R Ford1030-1050 Gynaecological ultrasound: Practice,pitfalls and liabilities1050-1110 Caring for patient and relatives afteradverse outcomes – the Mayo model1110-1130 Consulting with your colleagues –what, why, when, where and how?1130-1150 When in doubt, talk to your anaesthetist!1150-1210 Panel discussionJ MagrinaG CondousJ MagrinaK AtkinsonS Ford1530-1550 How to get through the litigation processM Keaney UMP1550-1610 ‘Be active, take the lead’ – advice from a colleagueJ Allan1610-1630 A personal journey through a Supreme Court caseA Kaye1630-1645 Panel discussion1645-1655 Post-conference Risk Management SurveyM McEvoyTransponder session1700 CloseA Lam7RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

AGES FOCUS MEETINGS 2007Challenges in PracticeSTRATEGIC BUSINESS PLANNING INOBSTETRICS AND GYNAECOLOGYAN AGES FOCUS MEETING IN ASSOCIATION WITH THE NATIONALASSOCIATION OF SPECIALIST OBSTETRICIANS AND GYNAECOLOGISTS (NASOG)AGES PELVIC FLOOR SYMPOSIUM & WORKSHOP VIII 20078 & 9 November 2007 Adelaide Convention Centre, Hyatt RegencyAGES 2007 XVII ANNUAL SCIENTIFIC MEETING• Help! - Trusts, company structures and tax planning• New technology in medical practice• 10 years from retirement – how do I look?• Marketing and medical practice• Contemporary business management• Opportunity in the private and public sector24 & 25 August 2007 Sheraton Mirage, Gold CoastChairman: Dr Geoffrey ReidCo-Chairman: Dr David MolloyEstablishing and running an Obstetrics and Gynaecology practice is acomplex business. Many recent legal changes impact upon us, ourstaff, and our patients.Practice design and structure, employee agreements, new technology,ethical marketing, and sound financial management are topics whichshould be of prime importance to us – but often get buried beneath thedemands of clinical practice.This is a meeting for everybody. This is a meeting designed for newspecialists commencing practice, those whose practice could benefitfrom efficiency overhaul, and those starting to look towards retirement.All working specialists will benefit from this!The Sheraton Mirage on the Gold Coast is a favourite meeting placefor many of our members, and a great location to linger for theweekend with family. The social program will be relaxed - with theusual great outdoor BBQ by the beach.We look forward to welcoming you all to another fantastic andinnovative meeting on the Gold Coast.Chairman: Dr Robert O’Shea Co-Chairman: Dr Elvis SemanInternational Speakers:Professor L CardozoProfessor P Sand• Patient Evaluation• Procedures of Choice• Risk ManagementRecent advances in pelvic floor surgery, both laparoscopic and vaginalhave renewed interest in this pivotal area. Evaluation anddocumentation of defects is critical in making appropriate managementdecisions. The development of a plethora of operative procedures inrecent times has produced significant confusion. Gynaecologists areunsure as to their respective therapeutic benefits. Scientific evaluationis underway and will bear fruit in due course.Our focus will be on ‘Procedures of Choice’ for prolapse and urinaryincontinence. Our international and national faculty will analyse thelatest literature and make recommendations with regard to state-ofthe-arttreatment for these conditions.Risk management is of extreme importance in this field. Its applicationin clinical management and the use of surgical prosthesis will becovered in detail. The management of pelvic organ prolapse, remainsone of the most critical areas of gynaecological practice and we lookforward to another exciting meeting in Adelaide.8

PROGRAM ABSTRACTSTHURSDAY 17 MAY 2007Complications in gynaecological/ endoscopicsurgeryThursday 17 May / Session II / 0830-0850Magrina J F• Electroshield scissors (1:1200)• Open techniqueDetection Small Bowel Injury• Check entry trocar site: ‘Thru and thru perforation’• Run small bowel with Debakey clamps• In doubt? exteriorize bowel loopMajor vessel injury with blind trocar entry is commonly associatedwith:A) Minimal free intraperitoneal bloodB) Immediate drop in BPC) Large amount of blood exiting through the trocarD) Gas embolismThe two most common causes of death associated with laparoscopicsurgery are:A) Anesthesia and intestinal injuriesB) Anesthesia and major vessel injuryC) Urinary and intestinal injuriesD) Intestinal and major vessel injuriesIntestinal injuries during laparoscopic surgery are:A) More common than urological injuriesB) Commonly undiagnosed intraoperativelyC) Associated with a low morbidityD) Associated with a low mortalityTypes of laparoscopic complicationsComplications %Urinary 0.1-1.7Intestinal 0-0.4Major vessels 0.01-0.4Hernia 0.08-0.9Other 0.9-8.1Complications of LaparoscopyMortalityNo. PatientsFrequency1,374,827 4.4/100,000Complications of LaparoscopyCauses of Mortality %Anesthesia 40Intestinal Injury 20Major vessel injury 20Intestinal injuries1st or 2nd most common cause of death:Unrecognized in 38-68%!Mortality: 2.5-5%Intestinal injuries• Trendelenburg 30°• Bowel adhesions: avoid cautery• Ask if hospital checks for micro-defectsClin Obstet Gynecol 45:469, 2002Clin Obstet Gynecol 146:131, 1983Management small bowel injurieslaparoscopic or manual?• Marked blanching = thermal injury:Excise widely and close• Serosal injuries: no repair• Muscularis injuries: nurolon 4-0• Full thickness defect: inner layer running 3-0 Vicryl;outer imbricating nurolon 4-0Prevention rectal injuriesRectal probeAvoid cauteryIdentifying vagina, bladder and rectumDetection rectosigmoid injuries• Perforations: distend rectum with air under water• Submucosa defects: Methylene blue enemaManagement rectosigmoid injuriesWith colostomy-10-fold morbidity- hospitalization longer by 6 daysManagement rectosigmoid injuriesLaparoscopic or manual?-Same technique as for small bowel-No difference in outcome with or without bowel prepIntestinal injuriesPost-Op CourseVery Mild Symptoms!• No fever but tachycardia• Ileus-like– Bloating– Pain– No flatus• No appetite• I don’t feel well’Suspected intestinal injury- CAT scan- Laparoscopy9 RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSTrocar damages bowel, iliac artery, mesenteryDetection bladder injuriesIntraop: fill bladder with methylene bluePostop: cystoscopyNot helpful for thermal injuries!!!!Detection ureteral injuriesIntraop: Indigo Carmin IVPostop:Cystoscopy with Indigo CarminNot helpful for thermal injuries!!!!Management urinary injuriesBladderdouble layer runninginner full thickness 3-0 vicrylouter imbricating 3-0 vicrylUreterfish mouth interrupted 4-0 vicrylAuthor address: Javier F Magrina, MD.Professor of Gynecology,Mayo Clinic Scottsdale. Scottsdale, ArizonaAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGMajor vessel injury• Most common cause: Double blind entry– 50/50: Verres/Trocar• Mortality: 10-17%Entry complications• No entry deaths• No major vessel injury• No failed laparoscopy• No subcutaneous or omental emphysema• No gas embolism• No injury to stomach, colon, bladderLaparoscopy• Less common than with blind entry• Most common with lymphadenectomies• Laparotomy 50%• Blood transfusion 50%• Mortality 12%Laparoscopic urinary injuriesIncidence 0.02-1.7%Not diagnosed intraopBladder 9%Ureters 94%Laparoscopic urinary injuriesMost common:Injury: Bladder perforationProcedure: LAVH 65%Ureteral site injury: IP lig 30%Prevention of urinary injuriesFill bladder intraopVaginal probe or tube, cervical ringDissect bladder and uretersEmerging technologies and techniques:Introduction into clinical practiceThursday 17 May / Session II / 0850-0910Spigelman AWhile there has been rigorous assessment and testing of new drugsand new items of equipment, such formal evaluation of newinterventional procedures prior to their introduction into clinicalpractice has been lacking until recently. This presentation will outline:• why this situation has changed• what has changed• how the change has been implemented and• what the future may holdAuthor address: Allan Spigelman. Professor of Surgery & Head, StVincent’s Hospital Clinical School, University of New South WalesRisk Management – principles, practices andprocessesThursday 17 May / Session II / 0910-0930Keaney MRisk management has many definitions. Standards Australia defines arisk as:“The chance of something happening that will have an impact uponobjectives. It is measured in terms of consequences and likelihood”.The risk management process is defined as:10

THURSDAY 17 MAY 2007“The systematic application of management policies,procedures and practices to the tasks of establishing thecontext, identifying, analysing, evaluating, treating, monitoringand communicating risk”The objective of risk management is to reduce risk to the lowestpossible level that is commensurate with achieving an organisation’sor individual’s purpose.Strategies to manage risk include:• Risk avoidance• Damage control (lost prevention)• Risk transfer through insuranceIn the context of medical indemnity, risk management is the process ofreducing the incidence of adverse healthcare events and thenmanaging such events when they do occur to minimise the likelihoodof complaint and claim.A key component of healthcare sector risk management is identifyingand analysing predictable and preventable causes of adverse patientoutcomes and then developing strategies to minimise the riskprospectively.The 2004 Gynaecology Claims Review, a joint report of RANZCOG andUNITED Medical Protection, reviewed 252 claims notified between1990 and 2001. As well as identifying the relative incidence ofadverse gynaecological outcomes that led to claims, the reportattempted to determine causal factors that led to claims.In gynaecology, the most common adverse outcomes were injury tosurrounding organs and structures (bowel, ureter and bladder) andfailed sterilisation, which accounted for 50% of claims.Causal factors included:• Improper performance of procedure (27%)• Lack of informed consent (14%)• Delay in diagnosis of complication (10%)• Inadequate investigations (8%)• Incorrect choice of procedure (7%)Common themes that contributed to adverse events and then claimswere:• Inadequate communication (42%)• Inadequate documentation (31%)Finally, in this presentation I will provide a personal perspective aboutwhat strategies gynaecologists could employ to reduce the incidenceof adverse events and minimise their medico-legal risk, complaints andclaims.Author address: Dr Megan Keaney, National Claims Manager.United Medical ProtectionIncorporating Risk Management into clinicalpracticeThursday 17 May / Session II / 0930-0950McEvoy MIncorporating risk management into a gynaecological and obstetricpractice in either public or private settings is an ongoing challenge forus all. Most of us think that this simply involves going to a surgicalconference or update .But this is only a start.A practice risk management system is any process involving thepractice and the patient that may impact on whether the patient suesthe doctor or not. Critically examine how your practice is setup. Themodus operandi of the following areas are important : facilities, staff ,reception, communication, financial information, screeningquestionnaires, confidentiality, patient information leaflets, listeningand communication skills, message forwarding protocols, after hourscontacts, communication with hospitals and referring doctors, pre andpost operative information, phone etiquette, handling of complaints,and finally surgical skill and clinical judgment.Identify any areas of weakness through complaints, staff meetings,medical insurers advice, meetings such as this, and preventrecurrences if possible. Discuss problems with colleagues, college,AMA, AGES, medical insurers. Reeducate yourself by going to coursesand conferences for lifelong learning.Adequate Risk Management is likely to reward you with reducedpremiums less insomnia, less suicide, less depression, and less stress.Key factors are good communication, education, adherence to ethicalstandards, keeping good contemporaneous records (especially with abad outcome or difficult patient), full debriefing and disclosure ofevents leading to difficult outcomes, full disclosure of financialinformation especially gap payments, adherence to respect for privacyand confidentiality, ability to negotiate and handle complaints, staffappointment and guidance, recordkeeping and consent processes.Informed consent and in particular failure to warn is an increasinglycommon problem in claims. Issues brought up by the patient, no matterhow trivial they seem to the doctor, are to be addressed seriously.Ultimately adequacy of consent is a legal not a medical judgment butwe could all improve. Issues material to the patient are important.Lifelong management of risk is the hallmark of all professionals. We inObstetrics and Gynaecology must learn to reduce this risk with soundmedical practices as well as addressing systems as above .This will inturn reduce stress suing premiums and anguish for the individual andthe collegiality of RANZCOGAuthor address: Dr Michael McEvoy. 41 Mann Tce, North Adelaide.Womens and Childrens Hospital, North Adelaide South Australia11RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGInformed Consent – Good medicine ordefensive practice?Thursday 17 May / Session III / 1045-1100Keaney M“Every human being of adult years and sound mind has the rightto determine what shall be done with his or her own body; anda surgeon who performs an operation without patient consentcommits an assault”.Schloendorff v Society of New York Hospital (1914)The 1992 High Court decision of Rogers V Whitaker confirmed thatmedical practitioners have a duty to:• Provide sufficient information for a patient to exercise choice• Warn a patient of any material risk inherent in any procedureIn determining what information should be conveyed to a patient themedical practitioner should take into account:• The nature of the recommended treatment or procedure• The expected benefits and possible risks• Alternatives to the recommended treatment or procedure• The natural history of the disease and the likely consequences withor without treatmentImportantly, information should be conveyed in a manner that isrelevant to the individual patient and in that sense context isimportant. Disclosure of risk will depend upon the severity andfrequency of the risk and the nature of the proposed intervention.Defensive medicine has been defined as:“Deviation from sound medical practice that is induced primarilyby a threat of liability” 1 .(Studdert et al 2005)Two types of defensive practice have been identified, being:1. Assurance behaviour – supplying additional services of little ofno clinical value to:• Reduce risk of adverse events• Reduce risk of claims• Enhance defensibility of claims2. Avoidance behaviour - avoiding patients or practices to reducemedico-legal riskIn one relatively recent US study of 824 doctors assurance behaviourswere reported by 93% of the group. 59% of the surveyed group ‘often’ordered unnecessary tests and 52% organised unnecessary referrals.32% often recommended invasive procedures.1The authors concluded that physician practices may be sensitive toswings in litigation and the insurance climate and perceptions aboutthe threat of liability were more important than personal experience.Is informed consent a defensive behaviour?I suggest that the answer to this question will depend upon whetherthe quality of communication is good or poor. Good communicationmeans that patient autonomy is respected and the responsibility fordecision making and good healthcare outcomes is properly transferredfrom the healthcare provider to the patient. Poor qualitycommunication may have the reverse effect and can be worse thanproviding no information at all. In medically paternalistic models ofcare, medical practitioners may attempt to retain responsibility for thehealthcare outcomes of their patients and may do so from a wellintentioned perspective.In a contemporary model of care where patient autonomy is central tonotions of good quality care, poor communication can mean thatpatients are not properly able to exercise their autonomy andhealthcare professionals may wrongly believe that they havedischarged their responsibilities in providing some, but inadequate,information. In these circumstances, adverse events can occurbecause of lack of continuity of care and complaint and claim are morelikely to occur following adverse outcome because of unmet patientexpectation.1Studdert, Mello and Sage et al 2005 “Defensive medicine among highrisk specialist physicians in a volatile malpractice environment” JAMA293 (21): 2609Author address: Dr Megan Keaney, National Claims Manager.United Medical ProtectionThe art and science of good communicationThursday 17 May / Session III / 1100-1120Walton MEfforts to improve the quality and safety of health care have includedexamining lessons from other industries such as aviation and transport.Unlike these industries health care is essentially a people industrywhere communication is central to health care outcomes. Machinescannot ever replace human interactions. We are now only beginning tounderstand that communication is not just about conveyingcompassion and empathy to patients and their carers (the art ofcommunication); it is also essential to the success of treatments (Thescience of communication). How well health professionals understandand manage their communications is directly associated with patientoutcomes. These aspects of communication will be explored in thissession.12

THURSDAY 17 MAY 2007Laparoscopic retroperitoneal anatomy of thelateral pelvic wallsThursday 17 May / Session IV / 1330-1350Magrina J F13RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETING14

FRIDAY 18 MAY 2007Bowel injury – case presentationFriday 18 May / Session VI / 0800-0830Karthigasu KUnintentional bowel injury, allbeit uncommon, is one of the mostfeared complications of laparoscopic surgery. If undiagnosed it has ahigh rate of mortatility and has a high rate of morbitity with itstreatment. It also accounts for a major part of legal action associatedwith laparoscopic surgery. In this session we aim to present a numberof cases of bowel injury and discuss the diagnosis and treatment usingthe most recent evidence, expert opinions and expert panel discussion.Bowel Injury - Evidence-Based analysis anddiscussionFriday 18 May / Session VI / 0800-0830Tsaltas JIn this presentation I would like to discuss the general risks of BowelInjury from operative laparoscopy. The generally accepted risk ofbowel injury is between 1 in 1000 and 1 in 2000. Injury can occur atthe time of entry, primary and secondary or during the operativeprocedure.In the second part of my talk I would like to discuss 2 cases of plannedbowel resection for severe endometriosis. Both these cases had a leakfrom their anastamosis. The accepted leak rate from bowel surgery isbetween 3 to 10%.I will present the literature on bowel resection and the riskmanagement process I employ to deal with both operative laparoscopyand also planned bowel surgery.Author address: Jim Tsaltas. Head of Gynaecological Endoscopy.Monash Medical CentreVascular injury – a case presentationFriday 18 May / Session VI / 0830-0900Merkur HA case history of a vascular incident at gynaecological surgery will bepresented. The case will be presented in chronological order of theevents that occurred on the day of the procedure.The transponder audience participation will enable a discussion of thealternatives for management in this case.Unexpected problems in laparoscopicmyomectomyFriday 18 May / Session VII / 1030-1050Lam AUterine myoma is one of the most common gynaecological pathology.In spite of upsurge in conservative treatment options for myoma inrecent year such as uterine artery embolisation, high-density focusultrasound, myolyis …, myomectomy remains the mainstay surgicaltreatment and one of the most common gynaecological procedures inwomen wishing to preserve the uterus.It is now well accepted that myomectomy can be performed either byopen or laparoscopic surgery. The preferred approach, however, is stilla matter of contention. Patients who have undergone ‘good’laparoscopic myomectomy would proclaim the benefits of minimalaccess surgery. On the other hand, theater staff and surgeons involvedin prolonged or poorly performed laparoscopic myomectomy may havegood reasons to revert back to open surgery or to think twice beforerecommending this approach to the following patients.There is level I evidence to support the laparoscopic approach withseveral prospective, randomized trials showing the early outcomes oflaparoscopic and abdominal myomectomy are similar in efficacy,safety, reproductive performance. Despite this, many have continued toargue that the laparoscopic approach is appropriate in a ‘few’ highlyselected patients. The reasons for this argument are variable, but aremostly to do with problems which can arise in myomectomy.Broadly speaking, the potential problems associated withmyomectomy, open or laparoscopic, may be classified into two groups- expected and unexpected.Potential expected problems in myomectomy, both in open andlaparoscopic surgery, include:• potential haemorrhage• potential need for blood transfusion• entry into endometrial cavity• risk of hysterectomy in case of life-threatening hemorrhage• pelvic infection• adhesionsPotential expected problems which are more specific to laparoscopicthan open myomectomy include:• tissue traction• uterine closure• adequate and timely haemostasis• specimen retrievalAdditional potential problems which are unexpected in laparoscopicmyomectomy may be divided into:• technical issues- related to fibroid retraction eg broken myoma screw- related to specimen retrieval – colpotomy, mini-laparotomy,automatic morcelllator15RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETING• pathological issues- fibroid degeneration making tissue retraction and removalfor difficult- adenomyosis- sarcomatous changeOn the whole, surgeons who wish to be successful, safe and efficientat laparoscopic myomectomy should develop their own check list ofpotential problems and ensure that they are able to systematically tickthese off candidly when counseling individual patient requiringmyomectomy. This is a practical way of risk-managing potentialproblems which may be associated with laparoscopic myomectomyand ensure appropriate patients selection and outcomes.Recommended reading:1. Hurst B. et al . Laparoscopic myomectomy for symptomatic uterinemyoma. Ferti Steril 2005; 83: 1-23.2. Stovall T, Mann W. Myomectomy UpToDate @www.uptodate.com3. Telinde’s Operative GynecologyAuthor address: Alan Lam, Associate Professor, Royal North ShoreHospital, Northern Clinical School, University of SydneyPitfalls, pearls, solutions to difficultlaparoscopic hysterectomyFriday 18 May / Session VII / 1050-1110Cutner ALaparoscopic hysterectomy can be classified according to the amountof the operation that is carried out laparoscopically and the amountvaginally. A useful system breaks the operation down into itscomponent parts. Thus the most simple is merely a diagnosticprocedure to confirm that the vaginal route is possible. The next levelis the taking of the infundibulo-pelvic ligament to make oophorectomyeasier at vaginal hysterectomy. The third level is the division of theround ligament and reflecting the bladder. Dissection extends down tothe uterine vessels. There is little benefit to this at it merely makesthem more likely to be sheared off during the vaginal procedure. Thefourth includes taking the uterine vessels laparoscopically which helpswith haemostasis when the vaginal component is difficult. The finalgroup is where the whole operation is carried out laparoscopically.This is obviously easier as the complete operation is carried out underdirect vision with better access than in a difficult vaginal hysterectomy.When considering laparoscopic hysterectomy it is important toconsider the indications, the impact that previous surgery may have onthe current surgery and the impact that current surgery may have onpossible future surgery. This paper will assess the implications oflaparscopic hysterectomy carried out in the following conditions:Gender-reassignment patients, the grossly obese, the presence oflarge fibroids, congenital uterine anomalies, endometriosis and inprolapse patients.Where there is a large pelvic mass, safe entry through the umbilicusmay be difficult and one should consider left sub-costal entry. Onceabdominal access is gained, views may be restricted due to theproximity of the mass to the telescope and it may be necessary toplace the scope just below the xiphisternum. Once there is anadequate pneumoperitoneum and if it is placed under direct vision, thisis perfectly safe and will enable adequate views for the procedure. Itmay be that the mass is too large to deliver vaginally and the lowerpedicles are hard to visualise. In these cases a sub-total hysterectomywith morcellation prior to removal of the cervix will help with access.The concerns for patients undergoing hysterectomy for gender reassignmentare twofold: There is likely to be limited access due tominimal uterine decent and a narrow introitus due to the effects oftestosterone and it is important not to damage the inferior epigastricvessels as there provide the blood supply required for phaloplasty.Thus ports should be kept very lateral and the vessels identified priorto post placement. This risk make the laparoscopic route especiallyattractive as an open route would require a midline incision.In the grossly obese patient the risks versus the benefits of surgeryneed to be considered. Where the patient has endometrial cancer therisks are outweighed by the benefits. Laparoscopic surgery is stronglyindicated due to reduced risks of burst abdomen, DVT risk and therespiratory compromise that an open operation through a large incisionwould cause. Although these operations are very difficultlaparoscopically, the open route is by no means an easy option. Thefirst consideration is the anaesthetic support as head down tiltbecomes a greater requirement and results in greater compromise inthis group. Longer ports are required for the operation and a totallaparoscopic approach is preferable as vaginal access is very difficult.Where access is difficult and bowel needs to be retracted additionalports may be helpful. We sometimes use 5 ports (not including thescope) in very difficult cases. The cosmetic result is not of concern andthe recovery is not altered. To struggle unnecessarily resulting in acomplication or conversion is a far worse outcome.Patients with mullerian anomalies fall into separate groups depending onwhether future pregnancy is possible. This is determined by the size andposition of the uterus. Symptoms will be determined by whether there isendometrium present and whether the uterus is obstructed orcommunicating. Also up to 30% of this group will have concomitant renalanomalies. This may take the form of absent kidney on the affected sidedor a duplex system. Thus pre-operative imaging is mandatory.With regards hysterectomy for endometriosis, it is important to tacklethe surgery as an endometriosis case with the addition of ahysterectomy. Careful ureteric dissection is essential as the positionwill be altered and consideration given to ureteric stents. It is essentialthat recto-vaginal disease is dissected out otherwise symptoms willnot resolve.For prolapse patients, the concept of a laparoscopic approach isrelatively new. However vaginal procedures are compromised byureteric proximity and the lack of access to fixed points to attach theareas of repair. From the vault perspective a high utero-sacralincorporation can be achieved after releasing incisions for the ureters.The vault can also be fixed using sutures to the sacral promontory. The16

FRIDAY 18 MAY 2007use of mesh at the time of hysterectomy is slightly controversial butcan be considered if a sub-total is to be performed. Addition of anteriorcompartment fixation via the cave of retzius will help reduce the rateof recurrent cystocele. However for prolapse perhaps the greatest gemis in the application of uterine suspension techniques whichlaparoscopy lends itself to so well.Author Address: Dr Alfred Cutner UCLHEndometrial ablation: Best practice in 2007Friday 18 May / Session IX / 1530-1550Maher P JMenstrual abnormalities are responsible for 12% of referrals togynaecological practice. Until the advent of less invasive techniquessuch as endometrial ablation/resection, most women who hadcompleted their reproduction would face hysterectomy.Endometrial ablation techniques have a common endpoint whichinvolves thermal destruction of the superficial endo- myometrium withsubsequent reduction in the amount of troublesome bleeding. Goldrathin 1981 reported the use of laser to produce photo- vaporization of theendometrium.Pre-operative assessment of these patients is essential. Tests includehysteroscopy or saline infusion sonography and endometrial samplingto exclude a malignant or pre-malignant cause of the menorrhagia.Depending on the technique chosen, it may be necessary to discussthe place of hormone preparations which result in thinning of theendometrium and the place of regional versus general anaesthesia.Initially laser was the tool of choice. Nd-YAG and Argon lasers werethe most popular types used in the early days of this operation. Bothmodalities were expensive and were not readily available in mostgynaecological institutions. The urological resectoscope, readilyavailable, was seen as a viable alternative to laser and the resultswere comparable in trained hands.Van Caillie and Lim in different countries almost simultaneouslypublished on the place of rollerball ablation as opposed to resectionwith results that suggested that this new technique would be morepopular due to ease of use and satisfactory results.Maher and Hill (1990) published the first series of this technique in theAustralian literature using a combination of resection and ablationwith success rates reported as high as 85%. The main stumbling blockto the uptake of these new endoscopic techniques was the learningcurve attached to them. Many practitioners, not even skilled indiagnostic hysteroscopy, adopted ablation but the results published byexperts were not met by the general gynaecologists. As a result thenew alternative to hysterectomy, enthusiastically quoted as the “laserhysterectomy”, fell in to disrepute and the initial boom in uptakerapidly fell away to a trickle. Then came the second generation ofablation systems generally called the global ablation systems (GAB).All of the new systems outcomes were measured against the outcomeof the rollerball ablation.There was a plethora of new devices: Thermachoice, Cavaterm,Novasure, HTA, Vestablate system, MEA, Her Option and the ELITTsystems. The trials and outcomes of all of these systems will bediscussed during the presentation. Newer treatments such as the LNGIUD (Mirena) system have had an impact on the use of G.A.S. Bestpractice in 2007 includes an understanding of the system chosen. Thepatient must be given all alternatives before a particular surgical eventis undertaken.Hysteroscopic skills are essential including the ability to resect bothendometrium and fibroids. Modern technology is very complex andmany things can go wrong. If the patient is asleep on the operatingtable and the computer controlling the G.A.S. crashes, the “show mustgo on” i.e. the operation must be completed by the tried and provenmethod of transcervical endometrial resection/ablation.Author address: Peter J. Maher Mercy Hospital for Women,Melbourne, VictoriaThe dissatisfied patient after endometrialablationFriday 18 May / Session IX / 1550-1610Abbott JMost literature in this area reports patient satisfaction levels of 80-95%. Whilst only a minority of patients then are likely to bedissatisfied, their needs are often great. For all of the first and secondgeneration endometrial ablation procedures, patient dissatisfactionfollowing the intervention is most likely to be due to one of threeproblems:1. Failure of the procedure to control menorrhagia2. Occurrence of de novo pain3. Complication(s) associated with the procedureFailure rates from these procedures are reported between 5-20% withup to 10 years follow-up. Failure of the procedure is not synonymouswith dissatisfaction and open discussion with patients of likelyoutcomes may be of benefit in this regard. Ongoing heavy mensesoften necessitates further intervention and hysterectomy is a commonoutcome for a significant group of these women. Repeat interventionrates range between 10-40% and should also be discussed preoperativelywith patients. The occurrence of new pathology mayaccount for repeat intervention but may be a source of dissatisfactionif the patient was unaware of this possibility. De novo pain occursfollowing between 1-5% of procedures and treatable causes such ashaematometra or endomyometritis must be recognised early. Theoccurrence of the later is particularly important since it is lifethreatening. The occurrence of de novo pain without a cause followinginvestigation is best managed by hysterectomy. Significantcomplications such as perforation or haemorrhage are uncommon andthe MISTLETOE study reports this to be 2.1% for rollerball to 6.4% for17RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGTCRE. No similar size study has been undertaken with secondgeneration procedures, designed to overcome many of thesecomplications. Visceral injury following ablation is an uncommon butserious outcome and is likely to result in prolonged hospitalisation,multiple procedures and even death. Such complications almostalways result in significant dissatisfaction. Subsequent pregnancy is acommon cause for both dissatisfaction and a complication rate of 50%.Patients should always be alerted to the need for contraception toavoid this. It may not be possible to avoid dissatisfaction in womenwho have an endometrial ablation. Discussion of likely outcomes,including the possibility of a failure rate that is often independent ofsurgical skill, may assist to improve satisfaction.Author address: Jason Abbott B Med (Hons) MRCOG FRANZCOGPhDRoyal Hospital for Women and University of New South WalesFluid management: the ins and outs ofhysteroscopic surgeryFriday 18 May / Session IX / 1610-1630Varol NObjective: To provide safe guidelines to minimize the risk of fluidabsorption and its complications at operative hysteroscopy.Design: Retrospective review of the literature.Results: Two of the major complications of fluid intravasation athysteroscopic surgery are hyponatraemic encephalopathy and death.Fluid intravasation remains a risk despite ideal instrumentation and theuse of minimum pressures to distend the uterus. While multiple factorsaffect the amount of fluid absorption and significant variability canexist between very similar cases, monitoring of fluid balance remainsthe most important issue. Techniques relying on volume measurementsare less accurate than those using weight measurements and canpotentially lead to significant underestimation of fluid absorption. Acontinuous automated weighing system provides an easy, less timeconsumingand valid method of monitoring fluid deficit. The safe limitfor accurately measured fluid loss should be 800mls as 1000mls ofglycine intravasation results in a very significant decrease in serumsodium that is sufficient to bring a normonatraemic patient in theabnormal range. It is safer to perform hysteroscopic surgery under localanaesthesia as the earliest symptoms of encephalopathy, ie. nausea,vomiting, weakness, will alert the surgeon and anaesthesist aboutimpending serious complications and corrective measures can be takenearlier than when the patient is under general anaesthesia.Conclusion: Fluid overload with subsequent hyponatraemicencephalopathy and death is one of the most significant complicationsin operative hysteroscopy. Following a protocol that entails the use oflocal anaesthesia, accurate fluid monitoring, and sets a limit to fluiddeficit, will minimize this risk.References:1. Overton C, Hargreaves J, Mareshr M. A national survey of the complicationsof endometrial destruction for menstrual disorders: the MISTLETOE study. BrJ Obstet Gynaecol 1997; 104: 1351-1359.2. Dwyer N, Hutton J, Stirrat GM. Randomised controlled trial comparingendometrial resection with abdominal hysterectomy for the surgicaltreatment of menorrhagia. Br J Obstet Gynaecol 1993; 100: 237-243.3. Magos AL, Baumann R, Lockwood GM, Turnbull AC. Experience with thefirst 250 endometrial resections for menorrhagia. Lancet 1991; 337: 1074-1078.4. Garry, R. Distension media and fluid systems. In: Sutton C, Diamond MP,eds. Endoscopic surgery for gynaecologists. London: WB Saunders, 1993:282-290.5. Molnar BG, Broadbent JA, Magos AL. Fluid overload risk score forendometrial resection. Gynaecol Endosc 1992; 1: 133-138.6. Siegler AM, Valle RF. Therapeutic hysteroscopic procedures. Fert Steril1988; 80: 685.7. Garry R, Mooney P, Hasham F, Kokri M. A uterine distension system toprevent fluid absorption during Nd-YAG laser endometrial ablation.Gynaecol Endosc 1992; 1: 23-27.8. Baumann R, Magos A, Kay JD and Turnbull AC. Absorption of glycineirrigating solution during transcervical resection of the endometrium. BrMed J 1990; 300: 304-305.9. Baggish MS, Brill AI, Rosensweig B, Barbot JE, Indman P. Fatal acuteglycine and sorbitol toxicity during operative hysteroscopy. J Gynecol Surg1993; 9: 137-143.10 Leake JF, Murphy AA & Zacur HA. Noncardiogenic pulmonary edema: acomplication of operative hysteroscopy. Fert Ster 1987; 48: 497-499.11. Jedeikin R, OlsfangerD & Kessler I. Disseminated intravascularcoagulopathy and adult respiratory distress syndrome: life threateningcomplications. Am J Obstet Gynecol 1990; 162: 44-45.12. Borten M, Seibert Cp & Taymor ML. Recurrent anaphylactic reaction tointraperitoneal dextran-75 for the prevention of postsurgical adhesions.Obstet Gynecol 1983; 61: 755-757.13. Loffer FD. Complications from uterine distention during hysteroscopy. In:Corfman KS, Diamond MP, DeCherney A, eds. Complications in laparoscopyand hysteroscopy. Boston: Blackwell Scientific Publications, 1993: 177-186.14. Van Renen RG, Reymann U. Comparison of the effect of two heights ofglycine irrigation solution on serum sodium and osmolality duringtransurethral resection of the prostate. Aus N Z J Surg 1997; 67: 874-877.15. Garry R, Hasham F, Kokri M, Mooney P. The effects of pressure on fluidabsorption during endometrial ablation. J Gynecol Surgery 1992; 8: 1-9.16. Hasham F, Garry R, Kokri M, Mooney P. Fluid absorption during laserablation of the endometrium in the treatment of menorrhagia. Br J ObstetGynaecol 1991; 68: 151-154.17. Magos AL, Baumann R, Turnbull AC. Safety of transcervical endometrialresection. (letter) Lancet 1990;6:44.18. Istre O, Bjoennes J, Naess R, Hornbaek K, Forman A. Postoperative cerebraloedema after transcervical endometrial resection and uterine irrigation with1.5% glycine. Lancet 1994; 344: 1187-89.19. Hawe JA, Chien PF, Martin D, Phillips AG, Garry R. The validity ofcontinuous automated endometrial surgery: luxury or necessity? Br J ObstetGynaecol 1998;105:797-801.20. Loffer FD. A comparison of hysteroscopic techniques. In: Lewis VB, Magos18

FRIDAY 18 MAY 2007AL, eds. Endometrial ablation. Edinburgh: Churchill Livingstone, 1993: 143-150.21. Brooks PG, Serden SP, Davos I. Hormonal inhibition of the endometrium forresectoscopic endometrial ablation. Am J Obstet Gynecol 1991; 164: 1601-1606.22. Donnez J, Schrurs B, Gillerot S, Sandow J, Clerckx F. Treatment of uterinefibroids with implants of gonadotropin-releasing hormone agonist:Assessment by hysterography. Fertil Steril 1989; 947-950.23. Serden SP, Brooks PG. Preoperative therapy in preparation for endometrialablation. J Reprod Med 1992; 37: 679-681.24. Perino A, Chianchiano N, Petronio M, Cittadini E. Role of leuprolide acetatedepot in hysteroscopic surgery: a controlled study. Fertil Steril 1993; 59:507-510.25. Vercellini P, Perino A, Consonni R, Tespidi L, Parazzini F, Crosignani P.Treatment with a gonadotrophin releasing hormone agonist beforeendometrial resection: a multicentre, randomised controlled trial. Br JObstet Gynaecol 1996; 103: 562-568.26. Tien R, Arieff AI, Kucharczyk W, Wasik A, Kucharczyk J. Hypnatremicencephalopathy: is central pontine myelinolysis a component? Am J Med1992; 92: 513-22.27. Lockwood GM, Baumann R, Turnbull AC, Magos A. Extensive hysteroscopicsurgery under local anaesthesia. Gynaecol Endosc 1992; 1: 15-21.28. Broadbent JA, Magos AL. Trans-cervical resection of the endometrium(TCRE). In: Sutton C, Diamond M, eds. Endoscopic surgery forgynaecologists. London: WB Saunders, 1993 : 294-306.29. Arieff AI, Llach F, Massry SG, Kerian A. Neurological manifestations andmorbidity of hyponatremia: correlation with brain water and electrolytes.Medicine (Baltimore) 1976; 55: 121-9.30. Fraser CL, Arieff AI. Fatal central diabetes mellitus and insipidus resultingfrom untreated hyponatremia: a new syndrome. Ann Intern Med 1990; 112:113-9.31. Arieff AI. Hyponatremia, convulsions, respiratory arrest, and permanentbrain damage after elective surgery in healthy women. N Engl J Med 1986;314: 1529-35.32 .Auys JC, Wheeler JM, Arieff AI. Postoperative hyponatremicencephalopathy in menstruant women. Ann Intern Med 1992; 117: 891-7.33. Arieff AI. Management of hyponatraemia. BMJ 1993; 307: 305-8.34. Lyerly HK. Fluid and electrolytes. In: Year Book Medical Publishers. Thehandbook of surgical intensive care. Second edition. Chicago. 1989: 235-7.35. Adams RD, Victor M, Mancall EL. Central pontine myelinolysis: a hithertoundescribed disease occurring in alcoholic and malnourished patients.Archives of Neurology and Psychiatry 1959; 81: 154-72.36. Sterns RH. Severe symptomatic hyponatremia: treatment and outcome. Astudy of 64 cases. Ann Intern Med 1987; 107: 656-64.37. Arieff AI, Ayus JC. Endometrial ablation complicated by fatal hyponatraemicencephalopathy. JAMA 1993; 10: 1230-2.38. Worthley LI, Thomas PD. Treatment of hyponatraemic seizures withintravenous 29.2% saline. BMJ 1986; 292: 168-70.39. Ayus JC, Olivero JJ, Frommer JP. Rapid correction of severe hyponatremiawith intravenous hypertonic saline solution. Am J Med 1982; 72: 43-8.40. Cheng JC, Zikos D, Skopicki HA, Peterson DR, Fisher KA. Long termneurologic outcome in psychogenic water drinkers with severe symptomatichyponatremia: the effect of rapid correction. Am J Med 1990; 88: 561-6.41. Ayus JC, Krothapalli RK, Arieff AI. Treatment of symptomatic hyponatremiaand its relation to brain damage. A prospective study. N Eng J Med 1987;317: 1190-5.42. Hantman D, Rosier B, Zohlman R, Schrier R. Rapid correction ofhyponatremia in the syndrome of inappropriate secretion of antidiuretichormone: an alternative treatment to hypertonic saline. Ann Intern Med1973; 78: 870-5.43. Sarnaik AP, Meert K, Hackbarth R, Fleischmann L. Management ofhyponatremic seizures in children with hypertonic saline: a safe andeffective strategy. Crit Care Med 1991; 19: 758-62.Author address: Dr Nesrin Varol. Royal Prince Alfred Hospital, SydneyHysteroscopic tubal sterilization: techniques,outcomes, challengesFriday 18 May / Session IX / 1630-1650Rosen DHysteroscopic sterilization, whilst long attempted, has come of age inthe early years of the 21st century. There are now a number of newproducts on the market or soon to be introduced to the market whichwill see this mode of female sterilization become an accepted andwidely utilized technique. Despite its safety and efficacy however, itwill only be offered by a number of practitioners due to the technicalchallenges involved in the procedures. This lecture looks at the historyof hysteroscopic sterilization to outline the path to today’s techniques,reviews the trial results of the Essure and Adiana systems andintroduces the newer products that will come to market. In addition,various technical issues will be addressed to aid the practitioner andthe health market will be reviewed in terms of the place ofhysteroscopic sterilization in the wider device market.19RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGThe hospital setting - ‘The good, the bad andthe ugly’ in endoscopic surgerySaturday 19 May / Session X / 0830-0845Cario GThe most high risk area of our work is in the hospital setting. It isessential that we pay great attention to this area in relation to riskmanagement. You are unlikely to face litigation as a result of anythingthat happens outside of this setting. We need to consider factors suchas patient selection, hospital selection and operation selectionconsistent with your experience and accreditation. Complete andoptimal patient preparation, information and consent are fundamentalas is the selection of your complete operative team, your operativeequipment and your instrumentation. The environment within thetheatre must be relaxed and conducive to risk avoidance, an excellentsurgical result and a well a happy content team. There should be clearleadership shown in times of crisis. Documentation is now a major toolin effective risk management and this will include a complete writtenaccount of the operation, including any difficulties encountered as wellas picture and video capture. Sharing the burden of complications bywell timed second opinions from other surgical colleagues is the markof maturity not incompetence. Once the operation is complete then thesecond phase of management begins that can equally be fraught withpitfalls. Concise post operative instructions to the nursing staff and thepatient and close follow up are essential to make sure that yourpatient is well established on their critical pathway when they aredischarged early from hospital. You must maintain an umbilical cord ofclose communication with the patient and your practise to determinethe early onset of complications and the possibility of readmission.Author address: Dr Greg Cario. Director of the Sydney Women’sEndosurgery CentreAdvanced endoscopic surgery in the NHSSaturday 19 May / Session X / 0845-0900Cutner AWhen assessing the potential for advanced laparoscopic surgery,certain factors need to be taken into consideration. These include theinfrastructure of the institution and this in turn will have an effect onthe level of financial support to enable the purchase of equipment thatis fit for purpose. Sophisticated equipment without trained surgeons isof no benefit. Likewise support staff to maintain and run theequipment is essential. Laparoscopic surgery necessitates the need fora team approach between surgical, nursing and technical support staff.One of the biggest drives for advanced laparoscopic surgery isindividual patients and patient support groups. The drivers that haveenabled advances to take place in the UK are the availability ofadvanced systems, which facilitate surgery. This together withincreased numbers of surgeons resulted in more teachers. Once thereis a critical mass of teachers, a snowball effect is achieved. In theearly days limitations of development was perhaps the desire for someto maintain surgical exclusiveness. When techniques became morewidely used, there was a rise in the number of complicationsoccurring. This resulted in restrictions and anxiety about adopting thistype of surgery. However as skilled surgeons adopted procedures, thenumber of teachers increased which enabled a secondary expansion ina safe manner.In the 1990’s due to several high profile cases of litigation, the RoyalCollege of Obstetricians and Gynaecologists set up an MAS subcommittee.The role of this committee was to facilitate theintroduction of safe laparoscopic and hysteroscopic surgery.Laparoscopic surgery was divided into 4 levels. Level one wasdiagnostic, level 2 minor operative, level three went up to LAVH. Level4 included urogynaecology, oncology, myomectomy, TLH, sub-totalhysterectomy and severe endometriosis. Interestingly there was onlyaccreditation for level three and no re-accreditation process.Candidates needed to go on a recognised course and have done areasonable throughput of cases and be signed up by their preceptor.Interpretation of data was at the discretion of the committee. Thelevels were later changed such that 2 and three 3 were combined andadvanced laparoscopic surgery became level 3. This meant that theaccreditation was for level 2. In 2003 the committee was disbandedwith the development of special skills modules. Again there was asystem to be accredited in level 2 work, but no system for advancedlaparoscopic surgery. The training however became supervised by thespecialist society (BSGE) on behalf of the college. In the UK we havejust had the introduction of “modernisation of medical careers”. Thishas resulted in a 2-year foundation program. On entry in obstetrics andgynaecology each trainee does 5 years of core training. After that theycan elect to do either sub-specialty training for 2 years or generaltraining for 2 years.The subspecialties include urogynaecology, reproductive medicine,maternal and fetal medicine, gynaecological oncology and sexual andreproductive health. Both the urogynaecology and oncology enable thedevelopment of laparoscopic surgery in these fields although theaccomplishment of the skills is not mandatory. If the trainee doesgeneral training they are required to do at least 2 advanced trainingspecial skills modules (ATSM). There is one in laparoscopic surgery butagain this is only at level 2. It is interesting that in the UK at thecurrent time you are required to be accredited to do a loop excision ofthe cervix but not to laparoscopically remove a nodule of bowelendometriosis. There is however hope for the future of advancedlaparoscopic surgery outside the recognised sub-specialties. The BSGEhas written a training program that has been through the committeenetwork of the college. It now needs to be submitted to thePostgraduate Medical Education and Training Board (PMETB). PMETBis the organisation that now has the legal responsibility for all UKmedical training. The college can merely advise but does not have thefinal say. The proposal is for a 2-year program alongside generaltraining to enable doctors to be accredited in these advanced areas.Apart form the development of advanced training there are two otherinitiatives that have occurred in the UK. The first is a postgraduate20

SATURDAY 19 MAY 2007degree in endoscopy, which does incorporate, advanced skills. It is ajoint venture between the BSGE and Surrey University. It has anacademic and a practical element. It is the first stage in accreditationbut is not attempting to be a substitute for a 2-year clinical trainingprogram. The other initiative is the establishment of BSGE badgedcentres for the laparoscopic treatment of advanced endometriosis. Thisfor the first time will result in set criteria for those carrying out thistype of surgery. Numbers of cases, team working and audit are theprimary aims of this initiative.So where has advanced laparoscopic surgery got to in the UK. Thereare the seeds to enable training and accreditation to develop andhopeful these will advance so that the litigation that occurred whenlaparoscopic surgery was initially introduced is not repeated. There aresome hospitals that do all there ectopics open whereas there areothers which have forward thinking management structure resulting inteams of surgeons and nurses that tackle cases at the same level asany institution in the world.Commonly, trials are planned, conducted, controlled, analysed andwritten up by people who are paid by industry – either directly (eg forrecruiting subjects or for ghost-writing a paper), or indirectly viaAdvisory Board positions, pseudo-consulting or speaking engagements.The result is massive and all-pervasive potential for bias. Jerome P.Kassirer, Professor of Medicine at Tufts University and former Editor inChief of the New England Journal of Medicine, has called the currentsituation ‘scandalous’. This state of affairs has become evident to thepublic, is eroding trust in industry, and adversely affecting publicperception of the integrity of the medical profession and of theresearch enterprise as such. In this paper I intend to give an overviewof current threats to the integrity of clinical research, as well assuggesting possible solutions, both on a personal and an institutionallevel.Author address: Associate Professor Hans Peter Dietz, SydneyAuthor address: Dr Alfred Cutner UCLHCorporate- clinician interaction and potentialeffects on patient careSaturday 19 May / Session X / 0900-0915Dietz HPWe are trustees of the common good, whether in clinical research or inday-to-day patient care. The public expect us to act in accordance withthis role. In practice this requires that we provide information throughresearch that is as ‘true’ as we can reasonably make it, and that weprovide care to the best of our abilities.There are many levels at which the ever- increasing influence ofmultinational corporations can impact on our role and affect patientcare and research. Industry provide us with the technology we need toprovide optimum care, and often help us to perform research that isthe basis for tomorrow’s best practice. However, the influence ofindustry can have negative effects as well. We all need to be aware ofthe ways in which Corporate- clinician interactions can affect both usand our relationship with patients. In the ultimate consequence, this isabout protecting our role, our reputation and our livelihood.In this talk I’ll focus not on personal ethics but rather on the ethics ofclinical research. This affects not just individuals, but the whole ofmedicine and society. It is self-evident that bias in published researchshould be reduced as far as possible, and modern research methodologyhas evolved to meet this goal. In therapeutic medicine, the double- blindmulticentre randomised controlled trial (RCT) is seen as the ‘goldstandard’ of bias reduction- developed in response to higher scientificand regulatory standards, and to fulfil the precepts of evidence- basedmedicine. Unfortunately, modern medical research, especially ifinvolving the pharmaceutical and device industry, is subject to forms ofbias that have received little attention to date, and they can affect amulticentre RCT just as much as a single surgeon observational series.21RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSRobotic Endoscopic surgery - advances orgimmicksSaturday 19 May / Session X / 0930-1000Magrina J FAGES 2007 XVII ANNUAL SCIENTIFIC MEETING22

SATURDAY 19 MAY 200723 RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETING24

SATURDAY 19 MAY 2007Gynaecological ultrasound: Practice, pitfallsand liabilitiesSaturday 19 May / Session XI / 1030-1050Condous GGynaecological ultrasound has evolved rapidly over the last twentyyears with the advent of high resolution transvaginal probes. Thediagnostic capabilities of pelvic ultrasound has transformed themanagement of common gynaecological conditions and earlypregnancy complications. This well-accepted, non-invasive, highlyreproducible diagnostic tool is as part of the work-up as the historyitself. Transvaginal ultrasound has meant that women with adnexalpathology can be triaged into expectant or laparoscopic or oncologicalstaging procedures, based on the ultrasonographic appearance of theovarian cyst. Remember, in experienced hands ultrasound canaccurately classify more than 90% of ovarian cysts. Similarly, morethan 90% of tubal ectopic pregnancy can be diagnosed with a highdegree of certainty using transvaginal ultrasound as a single diagnostictest. This means that the diagnosis of ectopic pregnancy tends to be atearlier gestations in more clinically stable women. Consequently, moreconservative treatment modalities have become acceptable practice inthe management of ectopic pregnancy.Ultrasound is not without its limitations and is indeed user dependent.In gynaecology, one must always be very aware of the clinical scenariowhen interpreting a pelvic ultrasound. Never base a woman'smanagement plan on ultrasound findings alone! One must interpret theendometrial changes on scan in the context of the menstrual cycle.Understanding the ultrasonographic appearance of a healthy femalepelvis is essential to diagnosing deviations from the accepted norm.Understanding the normal ultrasonographic milestones in earlypregnancy are essential for classifying miscarriage or non-viablepregnancies. Incorrect classification of viability in pregnancy orwrongly classified ovarian cysts can result in no untold measure ofmorbidity both surgically and psychologically for the patient.Stringent evidence based guidelines and risk triggers in gynaecologicalultrasound are obligatory in order to ensure the highest quality of care.The aim of this session is to discuss common ultrasound diagnosticshortcomings/dilemmas as well as ways to minimise risk in womenundergoing pelvic ultrasound.Author address: George Condous MRCOG, FRANZCOG AssociateProfessor in Gynaecology University of Sydney Nepean Clinical SchoolEarly Pregnancy and Advanced Endosurgery Unit Nepean HospitalSydney, Australia25RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGCaring for patient and relatives after adverseoutcomes: The Mayo modelSaturday 19 May / Session XI / 1050-1110Magrina J FMayo PhilosophyFull disclosure to patients (and families when appropriate) aboutoutcomes of care, including unanticipated adverse outcomesUnanticipated Adverse OutcomeDefinition: Result that differs significantly and adversely from whatwas anticipated by rendered treatmentMayo Informed Consent• Medical record– Options– Risks– Benefits– Patient understands– Patient agrees• Preop record– Patient signature– Other: Photos, videos, tissue handling,blood transfusions, etc.Unanticipated Adverse OutcomePlan for Patient/Family• Disclosure of facts to patient/family• Team approach: MD, RN, Legal, Social Worker, others.• Documentation in medical recordof dialogueUnanticipated Adverse OutcomeDisclosure to patient• Explanation in a factual manner• Answer questions objectively• Offer assistance: accommodations, contact family members,clergy, etc.• Provide information learned through subsequent evaluationsUnanticipated Adverse OutcomeInternal Plan• Inform– Risk Management– Legal counsel• Meet: All involved to performroot cause analysis• Action: Stop billing until clarificationUnanticipated Adverse OutcomeInternal Plan• If sentinel event ? activate policy• If Federal or State agency inquiry: Legal, Risk Management,Quality Management, Administration, others• If internal clinical medical peer review ? follow policyUnanticipated Adverse OutcomeInternal Plan• Depending on root cause analysis, Legal meets with patient/family– Explanation– CompensationUnanticipated Adverse OutcomeMy Plan• Inform family of outcome and internal plan• Call Risk Management ? Legal• Meet with Risk Management• Meet with all involved and Risk Management• Give patient/family all of my contact numbersincluding home phone number• Call patient frequently for support• Update information as it becomes available• I make myself available any timeAuthor address: Javier F. Magrina, MD. Professor of GynecologyMayo Clinic ArizonaConsulting with your colleagues – What, why,when, where and howSaturday 19 may / Session XI / 1110-1130Atkinson KWe now practise in a new era of accountability with every decisionand action closely scrutinised at all levels. Formerly the aim ofteaching programmes was to produce the complete Obstetrician andGynaecologist, proficient in most areas of the specialty. The resultwas reasonable for that time. Malpractice was black and white. Itwas unusual to be sued. Private practice was rewarding in more waysthan one and public work was performed on an honorary basis. Thesubscription to your indemnity provider was about the equivalent ofthe fee for one confinement. Doctor knew best, patients didn’t askquestions, there was no Health Care Complaints Commission and theBolam principle was well and truly entrenched ensuring that therewas always strong support from your colleagues if something wentwrong. Fortunately for patients and the profession things have nowchanged. A decade of intense medicolegal scrutiny has resulted in fargreater accountability and hopefully better outcomes. However, therehave been some trade-offs and one of these is the need to consultmore often.Why:This need has been largely driven by two major developments.• ConsentThere is a legal duty for doctors to disclose information about thenature, possible risks and benefits of treatment. Much has beenwritten about what constitutes consent and there have been a numberof landmark cases in Anglo-Australian law. Detailed guidelines havebeen produced by the NHMRC and most doctors are now aware ofwhat constitutes legal consent.26

SATURDAY 19 MAY 2007‘Informed consent’ is basically an American term but is frequentlymentioned in the context of providing exhaustive written informationwhich the patient is expected to read, understand and often sign. Myown experience is that most of us follow the published guidelines butnot necessarily in full. I also believe that this is often done badly. It isprobably not that useful to provide detailed and often poorlyunderstood written material unless requested. Most patients requirere-assurance that their best interests are being considered. They donot want to be unduly scared and, above all else, they need to haveconfidence in their doctor, that the practitioner has the necessary skillsto do what is needed and, if there is any doubt, will consult with asmany colleagues as necessary to maximise the prospects that the bestpossible outcome will result.• SubspecialisationOne of the major changes in medical education over the last twodecades has been the introduction of subspecialisation. It is nowembraced by most general specialties having been introduced andusually codified by way of examinations.To some extent it defines and also restricts the areas within which weas Obstetricians and Gynaecologists can practise. The hoped for resultis that patients will have the benefit of practitioners with greaterknowledge and expertise.Many areas are now well defined including oncology, urogynaecology,reproduction, foetal medicine and ultrasound. Others not so welldefined include endosurgery, sexual health, family planning, menstrualirregularities and medicolegal practice. Taken to the extreme, it leaveslittle room for the generalist and has had a significant impact ontraining programmes as well as access to treatment in remote areas.Thus, the combination of the provision of information and restrictionsin expertise will have the result of greatly increasing the need forconsultation of colleagues both within and outside the specialty.What:The short answer is anything with which the doctor may feeluncomfortable. This will include cases where the special expertise ofa subspecialist should provide a better outcome or where the patientrequests such a consultation. That doctor in turn should takecogniscence of the ability of the consulting doctor, should notnecessarily consider that the patient is being permanently referred andbe courteous enough to report back ideally before any intervention.The types of case are many and the consulted colleague shouldunderstand that the initial doctor may have the skills to handle thecase effectively.Many patients, particularly those facing surgery, have considerable comorbiditieswhich may require the pre-operative and continuingexpertise of someone from another specialty.When:The answer is as soon as possible and certainly as soon as the primarypractitioner is aware of any problem.In gynaecology, it should be prior to any intervention be it medical orsurgical. When the need for consultation is the result of anintraoperative or postoperative complication this should be early sothat any poor outcome can be minimised.The same is true for obstetrics. Many of the problems that occur havetheir antecedent cause in the antepartum period or even prior to thepregnancy. Surgical emergencies often require the assistance ofsomeone with special skills. This should be sought early before thesituation becomes irretrievable.Where and how:These two are interrelated. Consultation is always best when done ata formal level. Although there may be a place for telephone or corridorconsultation regarding general principles, this is unwise at theparticular level and can be a potent precursor to subsequent pooroutcomes and painful litigation.The consultation should ideally take place at a senior level and bedocumented. The tendency often to leave it to junior staff leads todelays, inappropriate consultations and poor background information.Messages left with secretaries, nurses and on the phone are often notreceived and frequently poorly understood.The same can also be said about handovers which are really anotherform of consultation. They are often poorly performed particularly bypractitioners who may be going away and will be uncontactable.The patient should also be aware that a consultation has been or is tobe arranged. When possible, particularly with serious treatmentissues or complications, an introduction to the consultant is not onlyhelpful but also courteous. The doctor initially involved in a seriouscase or complication should maintain an interest in the patient and theoutcome.Author address: Ken Atkinson – Royal Prince Alfred HospitalWhen in doubt, talk to your Anaesthetist!Saturday 19 May / Session XI / 1130-1150Ford SGynaecological laparoscopy and its associated pneumoperitoneum andTrendelenburg (head-down tilt) positioning have major physiologicalimplications for the anaesthetised patient and therefore theanaesthetist.Changes in venous return and systemic vascular resistance can alterventricular function and hence cardiac output. Respiratory function canalso be affected due to reduction in pulmonary compliance andalterations in lung ventilation/perfusion ratios with concomitantchanges in arterial blood chemistry (most notably reduced oxygen andincreased carbon dioxide tensions) (Chui et al, 1993).Nausea and vomiting is also a significant problem with generalanaesthesia particularly for younger female patients undergoinglaparoscopic pelvic surgery (Sinclair et al, 1999). Previous postoperativenausea and vomiting (PONV) further increases the chances ofproblems in the acute period following surgery (Gan et al, 2003).27RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGIn view of the physiological issues just raised, close communicationbetween gynaecologist, anaesthetist and patient in the preoperativeplanning stages is important in order to facilitate optimal preparationfor anaesthesia.Good communication has become imperative given the impressiveprogress in laparoscopic surgery to treat more complex and extensivegynaecological pathologies. Consequently, the anaesthetist has todeal with a greater diversity of patients in terms of age and preexistinghealth conditions. Patients with significant intercurrent comorbidity(valvular heart disease, obstructive sleep apnoea, severeasthma, diabetes mellitus, obesity and musculoskeletal disorders) needto be comprehensively assessed by the anaesthetist prior to hospitaladmission. In addition, those patients with previous severe PONV,suspected allergy to anaesthetic agents, or know upper airwaypathology all need to be identified.In my practice a formal anaesthetic pre-admission identificationprocess has proved most effective. It has facilitated comprehensive inroomsassessment and optimisation, previous anaesthetic recordretrieval and review, and detailed patient education and counselling.Decisions are then made regarding anaesthetic technique, postoperativecare, and in some cases surgical approach.In summary, the considerable interdependence between laparoscopicsurgery and anaesthetic management in context of complex diseaserequires close collaboration between anaesthetist and gynaecologistbefore and during hospital admission.References:Chui PT, Gin T, Oh TE. Anaesthesia for laparoscopic general surgery.Anaesth Intens Care 1993; 21:163-171.Gan TJ, Meyer M, Apfel CC, Chung F, Davis PJ, Eubanks S, Lovac A,Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M. Consensusguidelines for managing postoperative nausea and vomiting. AnesthAnalg 2003; 97:62-71.Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomitingbe predicted? Anesthesiology 1999; 91:109-118.Author address: Dr Stephen Ford. Consultant Anaesthetist, NorthShore Private and Mater Hospitals, Sydney.The Travelling Fellowship 2006Saturday 19 May / Session XI / 1210-1230Najjar HI have visited the Reproductive Specialist Centre in Milwaukee,Wisconsin in November 2006. It is one of the major centres in the USArun by Dr Charles Koh and Dr Grace Janik. The visit was over oneweek. The daily operating lists I attended with both doctors had anumber of complicated laparoscopic procedures including TotalLaparoscopic Hysterectomies, Laparoscopic Myomectomies, Tubalreananstomosis, and Excision of advanced Endometriosis with bowelresection. I have also attended an IVF session.Prior to going to Milwaukee I attended the AAGL Annual ScientificMeeting and a Robotic Surgery and Simulation Course in Las VegasAuthor address: Dr Haider Najjar FRANZCOG MBChB GynaecologicalEndoscopist. Monash Medical Centre Victoria Pager 03 9387 1000 14-16 Dixon Street Clayton VIC 3168 Tel 03 9652 8095 Fax 03 9543 2487Haider_najjar@yahoo.com.auAre we producing competent surgeonsSaturday 19 May / Session XII / 1330-1350Svigos J1. Historical concepts of Training2. Current RANZCOG Requirements for Gynae Surgical Trainingi. six years of training --- ITP & Electiveii. three monthly formative and six monthly summativeassessmentsiii. compulsory surgical skills workshopiv. IHCA –Colposcopyv. Minimum O&G procedural requirementsvi. Competency assessments of core O&G surgical procedures3. Competing influences on current Gynae Surgical Training.4. Surgical Training after Fellowship5. Future Challengesi. maximize surgical training opportunitiesii. simulators and surgical skills centresiii. training in private practice6. ConclusionReferences / suggested readings:www.ranzcog.edu.auRANZCOG Curriculum.RANZCOG Training Program Handbook 2007RANZCOG Training Handbook Supplement.RANZCOG Reaccreditation of ITP Hospitals : Standards& ProceduresAuthor address: Associate Professor John Svigos. Discipline ofObstetrics& Gynaecology. University of Adelaide. ConsultantObstetrician&Gynaecologist, Womens Health Specialists, NorthAdelaide. South Australia 5006The impact of NICE (National Institute of ClinicalExcellence) on clinical practice in the UKSaturday 19 May / Session XII / 1350-1410Cutner ANICE is an Independent organisation responsible for providing nationalguidance on the promotion of good health and the prevention and28

SATURDAY 17 MAY 2007treatment of ill health. It was established in its present form in 2005 atwhich time it assumed all its current responsibilities. It producesguidance in three areas of health. For public health, guidance relates tothe promotion of good health and the prevention of ill health for thoseworking in the NHS, local authorities and the wider public and voluntarysector. For health technologies, guidance relates to the use of new andexisting medicines, treatments and procedures within the NHS. Thisadvice applies to the NHS in England, Wales, Scotland and NorthernIreland. Clinical practice guidance reports on the appropriate treatmentand care of people with specific diseases and conditions within the NHS.This guidance relates to the NHS in England and Wales only. Topics to beidentified for review are determined by the Department of Health. SinceJanuary 2002, the NHS has been legally obliged to provide funding andresources in England and Wales for medicines and treatmentsrecommended by NICE’s technology appraisal guidance. The NHS mustensure it is available to those people it could help, normally within 3months of the guidance being issued.Interventional Procedures:An interventional procedure is defined by NICE as one that is used fordiagnosis or treatment and involves one of the following: Making a cutor a hole to gain access to the inside of a patient's body – for example,when carrying out an operation or inserting a tube into a blood vessel;Gaining access to a body cavity for example, examining or carrying outtreatment on the inside of the stomach using an instrument insertedvia the mouth; Using electromagnetic radiation (which includes X-rays,lasers, gamma-rays and ultraviolet light). This guidance looks atwhether interventional procedures are safe enough and work wellenough to be used routinely, or whether special arrangements areneeded for patient consent. Each procedure is given a rating. Guidanceranges from normal consent through audit and research to aclassification of “Do not use”. There have been 28 procedures eitherunder review or reports produced relating to procedures with someimpact on gynaecological endoscopy. It is interesting that they felt thatradical laparoscopic excision of endometriosis was not in their remit asthey considered that this procedure involved no more than the use ofconventional laparoscopic techniques in a specific part of the pelviccavity. This argument could be raised against many of the procedurethat they have produced guidance on such as the guidance entitledlaparoscopic radical hysterectomy for early stage cervical cancer.Clinical guidelines:These NICE recommendations are prepared by a group of healthcareprofessionals, representing the views of those who have or care forsomeone with the condition in question, and scientists. The grouplooks at the available evidence on the best way of treating ormanaging the condition, and makes recommendations based on thisevidence. There have been three guidelines that relate in part togynaecological endoscopy. These are the fertility, incontinence andheavy menstrual bleeding guidelines. The guidance given is graded aslevel A, B, C, D, or D(GPP). The last group means in the opinion of theguidance group. Interestingly clinical practice may be altered by theguidance when some is based on reasonable evidence. In theincontinence guideline there were 87 pieces of guidance issued. 20were graded as level D (expert opinion) and 41 as D(GPP). It wouldappear that the guidance on heavy menstrual bleeding is alsoinfluenced by personal opinion. This guidance does not favourhysterectomy as a treatment. It produces a table of risks patientsundergoing each treatment must be informed of. Hysterectomyincludes warning patients of the very rare risk of death. Interestinglythis risk is not included in the myomectomy or embolisation risks.Overall NICE has very laudable aims and there is a necessity for thistype of body. The reports make excellent reference guides but some ofthe conclusions appear to be driven by the aims of the group ratherthan the data presented.Author address: Dr Alfred Cutner UCLHIssues related to the application of mesh intothe pelvic floor repairSaturday 19 May / Session XII / 1410-1430Maher CLane initially described the use of mesh pelvic organ prolapse in 1962when he reported the sacral colpopexy 1 . Since that time the sacralcolpopexy has been popularised as the procedure of choice for uppervaginal prolapse with a higher success rate and lower dyspareuniathan following the vaginal based sacrospinous colpopexy. The problemremained the greater morbidity and cost of the sacral colpopexy ascompared to the vaginal approach 2 .In an attempt to improve durability of vaginal surgery many syntheticand biological grafts have been introduced into clinical practice witha paucity of supporting data that has been largely described byclinicians closely associated with industry. Many of the vaginal meshsurgical kits introduced worldwide have had the highest uptake ratesin Australia.In 2005 the Health Insurance Commission of Australia introduced anitem descriptor for the sacral colpopexy in response to the excellentsupportive data for this procedure. Despite excellent remuneration theuptake of the sacral colpopexy has been limited with the vaginalsacrospinous colpopexy being performed 10 x more frequently than thesacral colpopexy in the 2005-06 period 3 . During that time there hasbeen an explosion in the number of vaginal mesh kits performed inAustralia despite many peak bodies including the World HealthOrganization 2005 International Collaboration on Incontinence 4 and in2007 the American College of Obstetrics and Gynaecology clinicalguidelines 5 declaring the experimental nature of vaginal meshsurgeries and the need for consent forms to reflect this status.This presentation will discuss the possible reasons for the very limiteduptake of the sacral colpopexy and the very rapid uptake of the vaginalmesh surgeries. The risk management implications of this data for yourclinical practice will be explored.References:1. Lane F. Repair of post hysterectom vaginl vault prolapse. ObstetGynecol 1962;89:501-506.2. Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical29RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

ABSTRACTS SATURDAY 17 MAY 2007AGES 2007 XVII ANNUAL SCIENTIFIC MEETINGmanagement of pelvic organ prolapse in women. CochraneDatabase of Systematic Reviews 2004(4):CD004014.3. Australia M. Health Insurance Commission 2005-2006.4. Brubaker L, Bump RC, Jacquetin B, Karam M, Maher C. Surgery forpelvic organ prolapse, 2005.5. Smilen SW, Weber AM. Clinical management guidelines PelvicOrgan Prolapse. ACOG Practice Bulletin 2007;No. 79.Author address: A Prof Christoher Maher. Brisbane QLDBe active – take the leadSaturday 19 May / Session XIII / 1550-1610Allan JIntroduction: This talk will concentrate on the steps that I think agynaecologist should consider when served with a legal summonsrelating to an adverse medical outcome for one of his or her patients.The Summons: Be aware that the process servers can be summonedto give evidence in your case, especially if you decide to make anystatement about your case to them.Don’t make any important or hasty decision during that day and ifpossible see if you can cut back your workload for the remainder ofthe day.The “JOB” Syndrome (Why me, God?): It is not long before theJOB syndrome sets in, Why me, God? “I’m a good doctor, how couldthis happen to me?”The JOB syndrome can be associated with destructive reflection.Destructive reflection includes such thoughts as, Why was I born? Whydid I do medicine etc.? In some cases a state of chronic depressionwith long-term deleterious effect on one’s personal and professionallife can develop.The coping strategies: Failing winning the Lotto and moving toSpain, the doctor may find the following coping strategies useful.• Don’t alter your usual work schedules or practices.• Don’t curtail any social activities.• Learn about lawyers and the law. I joined the Medico-LegalSociety of Queensland.• Talk to anybody and everybody about your case(s), includingpatients. When I’m consenting patients for surgery, I notuncommonly refer to the actions against me and use them asexamples in the consenting process.• The more the defendant gets used to talking about the case, theeasier it will be if the case goes to trial and the details end up inthe press.• During the post summons period if your wife, husband, partner, etcsuggests you are becoming depressed, seek professional help froma clinical psychologist.Personal involvement in the case: Remember you are the one beingsued and you are paying the insurance premium. You therefore havethe right to have substantial input into the management of your case.It is also your responsibility to know exactly what stage the case is atand to be as helpful as you can to your legal advisers each step of theway. Indeed no significant decision with regards to the conduct of thecase should be made without your knowledge.Constructive not destructive involvement in the case is what isrequired from the doctor and this will be best achieved by beingeducated about every aspect of the case.What about the money? If the case gets to court then despite whatthe plaintiff might state in her pleadings, the whole fiasco is mostlyabout money. Don’t let such statements as “I just want to have my dayin court and see justice is done” or “It has nothing to do with money,”fool you into thinking that it is anything other than about money.It is also my opinion that the gynaecologist should resist the urge tosettle if we are not considered to be at fault. It might appear to be theeasy way out but I think we all know in the long run the easy optionwill turn out to be the expensive option and continue to make litigationattractive for the plaintiff.The Court Room: Be as educated as possible about every facet of thecase including having read all notes relating to the case. Have inputinto the selection of your expert witnesses, meet with your barristerand have a clear idea as to what questions may be put to you andwhat should be your response to the plaintiff's barrister's questioning.Apart from in the actual court room environment, have no contact withthe plaintiff.You will need to be in the court throughout the duration of the trial andpass your opinions on to your barrister as the trial progresses. Asmuch as possible control your feelings when answering questions, bebrief, to the point and don’t embellish the point. Don’t get smart.The Verdict/Conclusion: The significant emotional toll associatedwith medical negligence trials means that in the long run, despite whogets the money, there are no real winners.It is imperative that we the defendants employ every means at ourdisposal to avoid being consumed in this emotional maelstrom. If weloose sleep, alter our normal work or social habits, become depressed,then the plaintiff has won regardless as to the outcome of the trial.Author address: Dr John Allan, Clinical Director, WesleyReproductive Medicine and Gynaecological Surgery Unit, The WesleyHospital Auchenflower Brisbane30

FREE COMMUNICATIONS -AGES 2007 XVII ANNUAL SCIENTIFIC MEETINGLaparoscopic hysterectomy – the impact ofbody mass index (BMI) and outcomesThursday 17 May / Free Communications 1 / 1530-1540Soo S, Wang L, Merkur HStudy Objective: To investigate the operative and postoperativeoutcome for patients undergoing laparoscopic hysterectomy on thebasis of their body mass index.Design: The data was prospectively collected between 2004 and 2006and retrospectively analyzed. Peri-operative complications weredocumented and follow up was performed at 4 to 8 weeks in all cases.Setting: Advanced gynecological endoscopy teaching hospitals.Patients: Approximately three hundred patients undergoingLaparoscopic Hysterectomy for pelvic pathologyInterventions: Laparoscopic Hysterectomy completed with eitherLaparoscopic Assisted Vaginal Hysterectomy or Total LaparoscopicHysterectomy.Method: Patients were stratified into groups according to their BMI,normal (

LAPARASCOPIC HYSTERECTOMY - SESSION 1instruments. The technology in such equipment could be applied toimprove the techniques of traditional open surgery.Today we present a video of the performance of vaginal hysterectomywith the Harmonic Scalpel, and proposal for a randomized control trialto evaluate it against the traditional vaginal hysterectomy.Author address: Dr G Edwards, J Tsaltas, H Najjar, J Tan, A Fitz-Gerald. Monash Medical Centre, VictoriaComplications of total laparoscopichysterectomy: The Monash experienceThursday 17 May / Free Communications 1 / 1610-1620Tsaltas J, Lawrence A, Pearce S, Najjar H, Salfinger S,Tan JA retrospective review of medical records was performed to assess theincidence and type of significant complications encountered duringlaparoscopic hysterectomy from 1994 to end 2006. The operationswere performed at Monash Medical Centre, a Melbourne tertiarypublic hospital, and two Melbourne private hospitals, by threesurgeons. All patient records admitted for the procedure from 1994 toend 2006 was reviewed.Complications included ureteric fistula, bladder injuries, bowelobstructions, postoperative haematomas, bladder fistula andsuperficial epigastric artery injury. In-patient stay ranged from two tosix days. Rate of these complications will be discussed, and areconsistent with previously reported rates.The main complication outcome observed is the requirement of thepatient for further laparotomy, lapascopic or other procedures relatedto primary surgery complication.Author address: J Tsaltas, A Lawrence, S Pearce, H Najjar, SSalfinger, J Tan. Monash Medical Centre, Endosurgery Unit, VictoriaTotal laparoscopic hysterectomy pilot phase -Royal Women’s Hospital, Melbourne.Assessment of intra and post operativemorbidity and financial considerationsThursday 17 May / Free Communications 1 / 1620-1630Sgroi JC, Daly JO, Thomas PCObjective: The aim is to review the pilot phase of performance ofTotal Laparoscopic Hysterectomy at Royal Women’s HospitalMelbourne. Outcomes assessed included operative morbidity,conversion to laparotomy, operative time, blood loss, inpatient bedstay and assessment of the cost of the procedure.Population/Setting: All public patients undergoing Total LaparoscopicHysterectomy at the Royal Women’s Hospital, Melbourne, Australia,from November 2005 to January 2007.Methods and Materials: Thirty-eight patients were identifiedthrough the operating theatre reporting system and their medicalrecords reviewed. Information was obtained from the medical recordswith respect to the indication for surgery, overall theatre time,utilisation of disposable and non disposable equipment, inpatient bedstays, peri and post operatively complications and representations.Costs for equipment, in patient bed stays and the revenue obtainedthrough case mix funding were obtained from Finance Department.Results: There is additional cost of disposable equipment whenperforming a Total Laparoscopic Hysterectomy.The inpatient bed stay is significantly decreased, resulting in a netsaving to the hospital.The complication rate in the initial phase is low.Operative time decreases proportional to the number of casesperformed.Intra and post operative morbidity are in keeping with previous studieson Total Laparoscopic Hysterectomy.Conclusions: Total Laparoscopic Hysterectomy appears to befinancial viable when consideration is given to costs associated withperforming the procedure and the overall decrease in inpatient stay.Operative times decrease as the operator becomes increasingly skilledin the laparoscopic technique.Author address: Dr J Sgroi. Tel. 0408 422 665Email.joseph@mediconcall.com.au Gynaecological Endoscopy Unit,Royal Women’s Hospital, 132 Grattan St, Carlton, Melbourne, VIC3053, AustraliaSydney Women’s Endosurgery Centre statisticsand morbidity 2006Thursday 17 May / Free Communications 1 / 1630-1640Georgiou C, Johnston K, Cario G, Carlton M, Chou D,Cooper M, Reid G, Rosen DComplications during minimal access surgery are rare events.Therefore, data involving a consistent set of parameters, such as thesurgeons and peritoneal entry method are required to accuratelyassess these risks.At the Sydney Woman’s Endosurgery Centre the morbidity data fromthe established group of 6 laparoscopic surgeons have been collated toreport the complications which may occur.Data is presented on the type of surgery performed, the peritonealentry method (Verres, Hasson, Direct or Palmers) and the complicationsencountered during these surgeries.Such data will enable specific risks to be given to individuals abouttheir surgery performed in a specified unit. They may also serve as aguide to expected complication rates in other units.33RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

FREE COMMUNICATIONSAuthor address: Dr Chris Georgiou Bsc (Hons) PhD MBBS MRCOG.Sydney Woman’s Endosurgery Centre, St George Hospital (Private).Gray Street, Kogarah NSW 2217 Contact: 0402 600033Laparoscopic myomectomy with asupracervical ‘lassoo’Thursday 17 May / Free Communications 1 / 1640-1650Cario G, Georgiou CMyomectomy can be a challenge when performed using thelaparoscopic approach because of the back bleeding that occurs afterremoval of the fibroids from the myometrial bed. Failure to control thisbleeding may lead to open conversion. We have modified the SWEClassoo used to arrest back bleeding during Total LaparoscopicHysterectomy to temporarily occlude the uterine vessels which supplyalmost all of the blood to the myometrial bed . There is no need to tieoff the infundibulopelvic vessels. Once suturing of the myometrium iscomplete the lasso is cut without any trauma to these vessels. Wepresent a short video to demonstrate this technique.Laparoscopic mesh sacrocolpopexy for patientwith recurrent vaginal prolapse includinganterior and posterior Prolift.Thursday 17 May / Free Communications 2 / 1540-1550Georgiou C, Chou DA 61 years old multiparous lady who underwent 6 previous repairsincluding sacrospinous colpopexy, anterior and posterior Prolift andtransanal repair presented with recurrence of complete vault eversion.A video presentation of laparoscopic mesh sacrocolpopexy on thispatient will be presented.Author address: Chris Georgiou, Danny Chou. Sydney Women’sEndosurgery Centre (SWEC), Sydney, AustraliaA new biosynthetic material for pelvic floorrepairThursday 17 May / Free Communications 2 / 1550-1600Georgiou C, Cario G, Neethling WMLAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGFREE COMMUNICATIONS 2UROGYNAECOLOGYLaparoscopic mesh repair of a 12cm left glutealhernia in a patient previously managed withPerigee and posterior IVS plus mesh repair.Thursday 17 May / Free Communications 2 / 1530-1540Georgiou C, Fay L, Lubowski D, Chou DA 63 years old multiparous lady with long history of steroid dependentrheumatoid arthritis and bilateral mesh inguinal hernia repairunderwent Perigee and posterior IVS repair for severemulticompartment prolapse. Recurrence of vault prolapse andrectocoele necessitated further surgery 6 months later in the form of“Posterior vaginal sling” plus mesh placed over the posterior vaginalwall. Pt developed worsening of a left gluteal lump, which may havebeen present prior to her vaginal repairs. Pt had difficulty withevacuation and significant discomfort on sitting. CT scan revealed a3cm defect over left levator ani with loops of rectosigmoid colonherniated through. The hernia was reduced and hernial ring sutureclosed followed by mesh overlay. A presentation of pre andpostoperative imaging and surgical video will be presented.Author address: Chris Georgiou, Louise Fay, David Lubowski, DannyChou. Sydney Women’s Endosurgery Centre (SWEC), Sydney, AustraliaThe use of an appropriate material for pelvic floor repair depends onboth patient selection and the specific surgical problem. Differenttypes of mesh are available both synthetic and biosynthetic. Each typehas its own strengths and weaknesses. Specifically, the biosynthetictypes have limiting factors such as calcification and degeneration inglutaraldehyde preserved tissues which affects longevity afterimplantation.Preliminary data is presented in the use of an anticalcification processof decellularised matrix crosslinked with glutaraldehyde. It isenvisioned that bioimplants treated in this way may provide analternative biosynthetic type of mesh for pelvic floor repair.Author address: Chris Georgiou and Greg Cario. Sydney Women’sEndosurgery Centre (SWEC), Sydney, AustraliaSite-specific vaginal repairThursday 17 May / Free Communications 2 / 1600-1610Seman E, Behnia Willison F, Cook J, Lam C, Ayres H,Pena DThe urogynaecology unit at Flinders Medical Centre is conducting along term prospective study on the durability & safety of site-specificrepair of pelvic organ prolapse. To date we have recruited 114 womencommencing January 2004 & we present our 3 year data.The authors describe the range of defects diagnosed, criteria fortreatment inclusion, & the definition of surgical success. Each patientunderwent transvaginal site-specific repair of endopelvic fascial34

UROGYNAECOLOGY - SESSION 2defects, some with laparoscopic assistance +/- augmentation withSurgisis or a vaginal skin graft. Assessment entailed prolapsequantification with POPQ, before & after surgery, & documentation ofpostop complications, both early & late.We present the results of treatment , discuss the strengths &weaknesses of this approach & give our view on where site-specificrepair fits into contemporary practice.Laparoscopic paravaginal repair for anteriorvaginal prolapseThursday 17 May / Free Communications 2 / 1610-1620O’Shea R, Seman E, Cook J, Behnia-Willison F, Lam C,Ayres HSuccessful repair of anterior compartment prolapse has proved elusive.Anterior colporrhaphy has proved to have a high failure rate.Paravaginal repair was repopularised initially as an open procedure.Our experience has been with the laparoscopic approach. We presenta prospective observational study. All patients were treated betweenFebruary 1999 and December 2006, were assessed preoperativelyusing the Pelvic Organ Prolapse Quantification (POPQ) system andsubsequently assessed, postoperatively, on an annual basis thereafter.A total of 303 underwent laparoscopic paravaginal repair. Alaparoscopic Burch colposuspension was performed in 122 cases. Witha mean age of 60 years (31-89), mean weight 79kg (48-120), meanparity 2.9 (0-9), the average hospital stay was 4.2 days.With follow-up up to five years, objective success rate was 75%. Ofthe initial failures, 20 patients underwent a midline cystocoele repair,producing a two stage success rate of 83%. In addition 37 patients hadan asymptomatic midline cystocoele and declined further surgery,producing a success rate, in this group overall of 88%. These resultsare in keeping with our initial published data1,2. Laparoscopicparavaginal repair, in conjunction with midline cystocoele repairproduces highly acceptable results.References:1. Seman E.S., Cook J., O’Shea R.T. (2003) “A Two Year Experience ofLaparoscopic Pelvic Floor Repair – Journal American Association ofGynecological Laparoscopists. 10 (1):38-452. ‘Laparoscopic Vaginal Repair of Anterior Compartment Prolapse’Behnia-Willison F., Seman E, Cook J., O’Shea RT., Kierse M. JMinimally Invasive Gynecology: (2007) In pressAuthor address: Robert O’Shea, Elvis Seman, Jenny Cook, FaribaBehnia-Willison, Carl Lam, Hamilton Ayres.Flinders Endogynaecology.Flinders University, Flinders Medical Centre, Adelaide Australia.Laparoscopic supralevator repair posteriorcompartment pelvic organ prolapseThursday 17 May / Free Communications 2 / 1620-1630O’Shea R, Seman E, Cook J , Behnia-Willison F, Lam C,Ayres HTraditional surgery for posterior compartment prolapse involved aposterior colporrhaphy. Success rates for this procedure, haveproduced results ranging from 60-90% with relatively short follow-ups.The laparoscopic supralevator procedure was initially proposed by Lamand Rosen in 1997 as an approach for enterocoele repair. Our initialresults with two year follow-up (2003)1 produced objective 88%success rate. We present prospective observational study of 143 casesfrom February 1999 to December 2006. Patient characteristicsincluded, mean age 63 years (37-89), mean weight 71.9kg (48-124),mean parity of 2.9 (0-7) and average hospital stay of 4.3 days.Our average follow-up was 75 weeks ranging from 4 to 292 with followupup to 5 years. All patients were assessed preoperatively using thePelvic Organ Prolapse Quantification (POPQ) system and subsequentlypostoperatively, on a annual basis thereafter. Objective success rate ofthe procedure was 96%. The laparoscopic supralevator repair forposterior compartment prolapse has proved extremely successful. It ishowever, a technically difficult procedure and repair of the lowrectocoele may require a more traditional posterior colpoperineorraphy.Reference:1. Seman E.S., Cook J., O’Shea R.T. (2003) “A Two Year Experience ofLaparoscopic Pelvic Floor Repair – Journal American Association ofGynecological Laparoscopists. 10(1):38-45.Author address: Robert O’Shea, Elvis Seman, Jenny Cook, FaribaBehnia-Willison, Carl Lam, Hamilton Ayres. Flinders EndogynaecologyFlinders UniversityManagement of vaginal mesh erosion afterProlift® transvaginal prolapse repairThursday 17 May / Free Communications 2 / 1630-1640Al Nouh B, Singh SS, Lam AObjective: To review the presentation and management of vaginalmesh erosion after pelvic floor repair using the Prolift® transvaginalmesh system.Methods: 10 cases of mesh erosion are reported among 67 cases ofpelvic prolapse repair using the Prolift® system, from Feb. 2006 toDec. 2006. A literature review of reported mesh erosions using thesame surgical approach was also conducted to provide a summary ofthe international experience.Results: Cases are outlined based on preoperative history, surgicalprocedure, postoperative presentation and management of mesh erosion.35RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

FREE COMMUNICATIONSThe surgical technique for erosion repair is described and suggestions foralternative management options are also outlined. Seven of the tencases were in women undergoing repeat prolapse repair procedures andthree patients had concomitant suburethral sling procedures.Conclusions: Mesh erosion is a recognized complication of the totalvaginal mesh procedures for prolapse repair. Its management includesmedical and surgical approaches. Risk factors for erosion have beensuggested to include simultaneous hysterectomy and inverted Tcolpotomy. A lack of data exists regarding the risk of erosion inwomen undergoing a primary versus a recurrent prolapse repair.Though limited in number, the cases described offer examples for thegynaecologist who will see an increasing incidence of thispresentation as more mesh is used in pelvic floor reconstruction.Author address: Dr. Sukhbir Sony Singh MD, FRCSC (Ob/Gyn)Clinical Fellow,Centre for Advanced Reproductive Endosurgery, Suite408, 69 Christie Street, St. Leonards, NSW, 2065 Phone (office): 029966 9121 Fax: 02 9966 9126 Email: drsingh@sydneycare.com.au .Badria Al Nouh MBBS, DGO, ABOG Research Fellow, Centre forAdvanced Reproductive Endosurgery. Alan Lam MBBS (Hons), MRCOG,FRACOG, Associate Professor, Royal North ShoreHospital/University ofSydney, Centre for Advanced Reproductive Endosurgery (CARE), St.Leonards, NSWSurgical outcomes and complications ofvaginal Prolift® mesh repair for pelvicprolapseThursday 17 May / Free Communications 2 / 1640-1650Overall immediate postoperative morbidity occurred in 23 patients(35%) and included: fever (10.6%), UTI (10.6%), MI (1.5%), stroke(1.5%) and skin infection (1.5%). Readmission was required in theinitial postoperative period in 4 cases (6%). Erosion of mesh occurredin 9 cases (14%) overall with the majority being in the recurrentprolapse group (6/9). If considered separately, the erosion rate was17.6% in cases of recurrent prolapse repair and 9.4% in primaryrepairs. New onset dyspareunia, of varying degree, was found in 15patients (23%). Only 2 cases of procedure failure were documentedwith a mean follow up of 4 (± 3.5) months.Conclusions: The TVM technique is a novel approach to themanagement of pelvic floor prolapse. There appears to be a high shortterm success rate for prolapse correction, however, complicationsincluding erosion, dyspareunia and infection must be considered. Datafor this medical device is limited and requires further quality assuranceassessment, as done in this study, prior to wide adoption in generalgynaecology.Author address: Dr. Sukhbir Sony Singh MD, FRCSC (Ob/Gyn),Clinical Fellow Centre for Advanced Reproductive Endosurgery, Suite408, 69 Christie Street, St. Leonards, NSW, 2065 Phone (office): 029966 9121 Fax: 02 9966 9126 Email: drsingh@sydneycare.com.au.Badria Al Nouh MBBS, DGO, ABOG Research Fellow Centre forAdvanced Reproductive Endosurgery. George Condous MRCOG,FRANZCOG, Associate Professor in Gynaecology, Nepean ClinicalSchool, University of Sydney, Nepean Hospital, NSW. Alan Lam MBBS(Hons), MRCOG, FRACOG Associate Professor, Royal North ShoreHospital/University of Sydney, Centre for Advanced ReproductiveEndosurgery (CARE), St. Leonards, NSWSingh SS, Al Nouh B, Condous G, Lam AAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGObjectives: To report the early Australian experience with theProlift® transvaginal mesh technique for pelvic floor repair includingoutcomes and complications.Methods: Descriptive study of 66 consecutive patients undergoingProlift® repair for pelvic floor prolapse in 2006. The technique wasused in both primary and recurrent prolapse for women seen in anadvanced surgical practice with a single surgeon.Results: The patient demographics included a mean age of 58 years (±12), BMI of 26 (± 4.5), and 3 (± 1.6) previous pregnancies. Furtherdemographics and surgical data are presented below:Preop POP QType of ProliftStage 2 11 (17%) Ant 12 (18%)Stage 3 44 (67%) Post 8 (12%)Stage 4 9 (14%) Total 46 (70%)Prev. Prolapse Surgery 34 (52%)Uterus Intact 36 (55%)TVT or TVT-O 12 (18%)Mean OR Time (min) 109 (± 26)Mean EBL 174cc (± 117)Mean LOS 2.8 (± 0.8)FREE COMMUNICATIONS 3ENDOSCOPIC PROCEDURESHysteroscopic resection of caesarean sectionscar pregnancy – a treatment option for adifficult and increasingly common clinicalsituationFriday 18 May / Free Communications 3 / 1330-1340Deans R, Abbott J, Vancaillie TObjective: Embryo implantation in the region of a previous caesareansection scar is a rare but potentially catastrophic sequelae ofcaesarean delivery. There are a small number of such pregnanciesreported. Current data suggests expectant treatment is rarelysuccessful and termination of pregnancy is the management of choice.This may be completed by medical or surgical means, with or withoutimaging assistance. We present our experience at the Royal Hospitalfor women where 7 women have undergone hysteroscopic resection ofcaesarean scar pregnancies.36

ENDOSCOPIC PROCEDURES - SESSION 3Methods: Seven patients were diagnosed by transvaginal ultrasoundto have caesarean scar pregnancy between 2004 -2007 at the RoyalHospital for Women. An operative hysteroscopy was performed on allof these patients with cold removal of products of conception andhaemostasis by mechanical and medical means. Patients werefollowed on a weekly basis by clinical and biochemical means.Patients had a pelvic ultrasound at 3 months post procedure to reviewthe uterine cavity.Results: 7 women with caesarean scar pregnancies were successfullymanaged by primary hysteroscopic removal of products of conception.One woman had a slow return to a negative BHCG (3 months) and onewoman had significant haematuria, though no bladder complication.Operative time was short, blood loss was miminal with initialtreatment by mechanical compression in early cases, to expectantmanagement in later cases. The uterine echotexture returned tonormal by follow up ultrasound scan, and one woman has had asubsequent intrauterine pregnancy.Conclusions: Hyteroscopic management of caesarean scar pregnancyis a safe treatment option for this difficult clinical dilemma. It may beused with success as a primary mode of treatment, or as an option forfailed medical management.Author address: R. Deans, J. Abbott, T. Vancaillie. Royal Hospitalfor Women, Barker St, Randwick , NSW 2031Laparoscopic excision of retroperitoneal gonadin a patient with complete androgeninsensitivity: case report and videopresentation.Friday 18 May / Free Communications 3 / 1340-1350Cameron M, Maher P, Grover SComplete androgen insensitivity syndrome (CAIS) is a rare disorder ofsexual development. The typical mode of presentation is that of aphenotypic female presenting in mid-adolescence with primaryamenorrhoea in the context of normal breast development. Lesscommonly, presentation is in early childhood with bilateral inguinalhernias. Chromosome analysis reveals XY chromosomes, and pelvicultrasound will demonstrate absence of the uterus, and intra-abdominalor inguinal gonads. Treatment involves supportive therapy, hormonereplacement and gonadectomy, the timing of which is variable 1,2 .We present a case of a woman with CAIS who underwentlaparoscopic gonadectomy. Pre-operative ultrasound demonstrated thatone of the gonads was in close proximity to the common iliac vesselsand intraoperatively, this gonad was found to be retroperitoneal.Surgical technique will be demonstrated and the case discussed.References:1. Hughes IA, Deeb A. Androgen resistance. Best Pract Res ClinEndocrinol Metab. 2006 Dec;20(4):577-982. Alvarez NR, Lee TM, Solorzano CC. Complete androgen insensitivitysyndrome: the role of the endocrine surgeon. Am Surg. 2005Mar;71(3):241-3Author address: Dr Melissa Cameron. Endosurgery Unit, MercyHospital for Women, 163 Studley Road, Heidelberg VIC 3084. Ph. 038458 4901 Email: mcameron@mercy.com.auLaparoscopic cervical cerclage: a six stepapproach – a video presentationFriday 18 May / Free Communications 3 / 1350-1400Singh SS, Allen LM, Leyland NA, Thomas J, Windrim R,Whittle WLObjective: To describe the surgical technique developed and utilizedby the Toronto Laparoscopic Cervical Cerclage Group for interval andgravid cerclage placement.Methods: This video presentation outlines the background, techniqueand summary of outcomes for the laparoscopic cervical cerclage (LCC)as conducted at the University of Toronto (Canada). Indications for LCCinclude: history of one or more second trimester loss(es) due to cervicalinsufficiency; failed vaginal cerclage; and/or history of cervicalsurgery/trauma. Cerclage suture (#1-Prolene) was placed in bothpregnant and non-pregnant (interval) patients in a tertiary level settingwith collaboration between maternal fetal medicine and gynaecologiclaparoscopy specialists.Results: The laparoscopic cervical cerclage has been reported in casereports and small series throughout the literature since 1998. The TLCCGhas one of the largest series internationally. Since 2002, 55 cases havebeen completed and are being followed, 27 in pregnancy and 28 interval.The successful pregnancy rate is >80% with morbidity limited toconversion to laparotomy among 6 pregnant cases. No significantcomplications were noted in the interval (non-pregnant) patients.Conclusions: The Toronto approach to laparoscopic cervical cerclageoffers a simplified six step approach to suture placement which maybe done in pregnancy or as an interval (non-pregnant) procedure.Interval LCC appears to be technically feasible with no conversions tolaparotomy, no significant surgical complications and does not appearto impair conception. The pregnant LCC has a greater risk ofconversion to laparotomy due to greater technical difficulty. Overall,the LCC is associated with a reasonable rate of pregnancy success andthus may prove to be a less invasive alternative to the abdominalcervico-isthmic cerclage.Author address: Dr. Sukhbir Sony Singh MD, FRCSC (Ob/Gyn)Clinical Fellow Centre for Advanced Reproductive Endosurgery, Suite408, 69 Christie Street, St. Leonards, NSW, 2065 Phone (office): 029966 9121 Fax: 02 9966 9126 Email: drsingh@sydneycare.com.auSukhbir S. Singh a , Lisa M. Allen b Nicholas A. Leyland a , Jackie Thomas b ,Rory Windrim b , Wendy L. Whittle baSt. Joseph’s Health Centre, Division of Gynaecological EndoscopybMount Sinai Hospital, Dept of Ob/Gyn, 600 University Avenue,University of Toronto, Toronto, Ontario, Canada37RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

FREE COMMUNICATIONSCatheter-guided hysteroscopy: minimizingpatient discomfortFriday 18 May / Free Communications 3 / 1400-1410Laparoscopic excision of 3cm full thicknessendometriotic bladder nodule with Ligasure.Friday 18 May / Free Communications 3 / 1410-1420De Decker A, Kingston A, Vancaillie TGGeorgiou C , Aslan P, Chou DAGES 2007 XVII ANNUAL SCIENTIFIC MEETING38Introduction: One of the greatest challenges nowadays in outpatienthysteroscopy is reducing the patient’s discomfort. The patientparticularly experiences discomfort when introducing the hysteroscopethrough the cervical canal.Therefore, we offer the patient topical analgesia before starting thehysteroscopy using a catheter-guided technique.Technique:Topical intra-uterine analgesia is provided through 4cc oflignocaine solution, prepared by mixing 2 ml of 9.6% lignocainesolution with 2 ml of buffer. The solution is inserted into the uterinecavity using a catheter (Medgyn endosampler©, USA). The catheter is20 cm long and marked every 2cm. The last 5 cm of the catheter areangled at 15 degrees. Introducing the catheter provides information onthe orientation of the uterus and length of the uterine cavity. Afterinsertion of the lignocaine solution into the uterine cavity, the distal tipof the catheter is left in situ. While diffusion of the solution into theendo-myometrium takes place, the outpatient hysteroscope setting canbe prepared.During subsequent vaginoscopy, the catheter can be clearly visualised,allowing direct guidance to the external cervical os and thus reducingthe time needed to perform an outpatient hysteroscopy procedure. Apilot study conducted in our unit with 10 subjects showed significantreduction in time needed to introduce the hysteroscope into thecervical canal 1.27 versus 2.15 min p

GENERAL ENDOSCOPY - SESSION 4Cooper MJ. Broadbent JA. Et al. A series of 1000 consecutiveoutpatient diagnostic hysteroscopies. Obstet Gynaecol 1995;21(5):503-7Gillespie A. Nichols A. The value of hysteroscopy. Aust NZ J ObstetGynaecol 1994; 34(1):85-7Nagele, F. et al. 2500 Outpatient diagnostic hysteroscopies. ObstetGynecol. 1996;88(5):900-1Gordon S.J. Westgate J. The incidence and Management of FailedPipelle Sampling in a General Outpatient Clinic. Aust NZ J ObstetGynaecol 1999;39:115Dijkhuizen FP. MolBW. Brolmann HA. Heintz AP. The accuracy ofendometrial sampling in the diagnosis of patients with endometrialcarcinoma and hyperplasia: a meta-analysis. Cancer 2000; 89(9):1765-72Farrell T. Jones N. Owen P. Baird A. The significance of an‘insufficient’ Pipelle sample in the investigation of postmenopausalbleeding. Acta Obstet Gynecol Scand 1999; 78: 810-812Litta P. Merlin F. Saccardi C. et al. Role of hysteroscopy withendometrial biopsy to rule out endometrial cancer in postmenopausalwomen with abnormal uterine bleeding. Maturitas 2005; 50:117-123Clark T. Voit D. Gupta J. Hyde C. Song F. Khan K. Accuracy ofHysteroscopy in the Diagnosis of Endometrial Cancer and Hyperplasia.JAMA 2002; 288:1610-1621Author Address: Simon Ghaly - Intern Bankstown Hospital EldridgeRd, Bansktown 2200 Tel: 0421277575. Place of Study - Department ofEndogynaecology, Royal Hospital for Women, Randwick Sydney.Minimally Invasive Cervical DilatationFriday 18 May / Free Communications 3 / 1440-1450Tan J, Lee SAt present, dilation of the cervix is required for many routinegynaecological procedures. It typically involves use of a uterine sound,progressively larger Hagar dilators then introduction of other devicesand fluid. The procedure often requires a general anaesthetic and isassociated with pain, bleeding and uterine perforation in at least1.98% of dilatation and curettage cases. This equates to more than19.8 people in 1000 (Kaali SG, Szigetvari IA, Bartfai GS “Thefrequency and management of uterine perforations during firsttrimesterabortions” American Journal of Obstetrics & Gynecology1989 Aug;161(2):406-8). Pipelle sampling is not always possible in anoutpatient setting, and negative predictive value is poor.We now present a new novel invention/concept, granted internationalprovisional patent in Jan 2007: The Cervical Balloon Dilation Catheter.It is an elongate inflatable cyclindrical flexible catheter of 2mm whichcan be fed into the cervical canal prior to dilatation. Once inserted,markings on the catheter serve to sound the uterus. Inflation of thiscylindrical balloon serves to dilate/seal the cervical canal. This balloonhas a predetermined inflated diameter and is manufactured with anon-distensible elastomer which may develop pressures of up to100psi, similar to that of angioplasty catheters and akin to anenlarging Hager dilator. A lumen within the catheter enables thedelivery of fluid into the intrauterine cavity for hysterosalpingogram orliquid based endometrial cytology.Therefore, this device is able to sound, dilate and deliver fluid into theuterine cavity all in one device with a single placement/entry. It ishypothesized that this device will reduce anaesthetic requirement,uterine perforation rate and post-operative pain, although furtherstudies are pending.Author address: J Tan, S Lee. Monash Medical Centre, VictoriaFREE COMMUNICATIONS 4GENERAL ENDOSCOPY SESSIONCredentialing for advanced laparoscopicprocedures at southern healthFriday 18 May / Free Communications 4 / 1330-1340Vollenhoven B, Tsaltas J, Lawrence A, Shashian TRecently released AGES and RANZCOG guidelines state thatgynaecologists should not perform advanced laparoscopic proceduresuntil they are skilled in these operations.Southern Health, being a multi-site hospital organization have alsoreleased a policy to ensure that the six levels of laparoscopic surgeryare performed by appropriately trained surgeons.Level 1. Diagnostic laparoscopy.Level 2. Simple operative laparoscopy procedures; eg tubal ligation,cautery endometriosisLevel 3. Operative laparoscopy procedures such as ovarian cystectomyand oophorectomy and treatment of ectopic pregnancy wherethe pelvic anatomy is normal.Level 4. Operative laparoscopy procedures such as laparoscopicassisted vaginal hysterectomy (LAVH) and excisionalprocedures for stage III endometriosis.Level 5. Operative laparoscopy procedures such as total laparoscopichysterectomy (TLH), myomectomy or Burch procedures.Level 6. Operative laparoscopy procedures such as pelvic floor repair,excisional surgery for stage IV endometriosis, adnexal surgerywhere the anatomy is significantly distorted such as removalof residual ovary and oncological procedures.RANZCOG expects that at the completion of Fellowship trainingfellows should be able to perform up to level 3 procedures. TheGynaecological Endosurgery Unit at Moorabin offers specific furthertraining to enable current staff gynaecologist to be credentialed foradvanced procedures. We would like to describe our process of39RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

FREE COMMUNICATIONSAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGaccreditation within our institution.Author address: B Vollenhoven, J Tsaltas, A Lawrence, T Shashian.Monash Medical Centre Endosurgery Unit, VictoriaEditing of video/images data in endosurgeryFriday 18 May / Free Communications 4 / 1340-1350Georgiou CThe ongoing development of digital technology has enabled therecording of intraoperative endoscopic images to be stored in variousformats. This includes both movie and still images.The ability to edit and present such information allows the disseminationof techniques/ approaches and complications that occur duringlaparoscopic surgery. This helps the individual to refine and choreographtheir technique as well as providing an enhanced perception ofgynaecological procedures during multidisciplinary case presentations.The majority of the recording systems use a PC interface andconsequently the formats are predominately PC friendly. However, editingof the original raw data without loss of image quality can be challengingand usually requires the use of compatible software packages.A simple and relative inexpensive Apple Computer based solution ispresented which may be used by a department/ unit or individual.Author address: Dr Chris Georgiou Bsc (Hons) PhD MBBS MRCOG.Sydney Woman’s Endosurgery Centre. St George Hospital (Private)Gray Street Kogarah NSW 2217 Contact: 0402 600033Bladder dysfunction following gynaecologicallaparoscopic SurgeryFriday 18 May / Free Communications 4 / 1350-1400Chetty N, Abbott JAims: To review the incidence of voiding dysfunction after laparoscopicsurgery and explore factors that may contribute to this problemMethods: Between June and December 2003, all patients havingelective or emergency surgery for benign gynaecological disease wereretrospectively reviewed with regard to post-operative bladderfunction. Current practice is to perform post void bladder ultrasoundscans for residual urinary volume for all patients following removal oftheir in-dwelling catheter (IDC). Demographic and operative data werecollected including age, site of surgery, pathology, operative time,length of time IDC was in situ, void volumes, residuals and whethervoiding dysfunction specifically resulted in an increase to hospital stay.Results: Despite the limitations of a retrospective audit it appears thata 50% of patients having benign laparoscopic gynaecological surgeryhad some degree of voiding dysfunction. This did not correlate tolength of surgery, site of surgery or pathology.Discussion: The implications of post-operative voiding dysfunctionmay have consequences for health care resource utilisation, acutepatient management, possible long-term consequences for urinaryfunction and add to patient anxiety. Possible explanations for this highrate of dysfunction include normal bladder behaviour, unmasking futurebladder dysfunction, response to drugs, response to pain, learntresponse- (Hinman syndrome), a neurapraxia or other neurologicalproblem. These findings may also have economic considerations withregard to staffing and length of hospital stay. These high rates ofbladder dysfunction require further study.Key Words: Bladder dysfunction / Voiding / Laparoscopy / PostoperativeAuthor address: Naven CHETTY, Jason ABBOTT. Endo-GynaecologyDept. Royal Hospital for Women, Randwick, NSW. Naven Chetty,Endogynae.Fellow 11A Durham St, Stanmore, NSW, 2048 Ph: 0438636004A prospective, randomised, double-blind,placebo-controlled trial of multimodal intraoperativeanalgesia for laparoscopic excisionof endometriosisFriday 18 May / Free communications 4 / 1400-1410Costello MF, Abbott J, Katz S, Vancaillie T, Lenart M,Fawcett S, Walsh R, Wilson S, Lyons SObjectives: To assess the efficacy of multimodal intraoperativeanalgesia in reducing post-operative pain and/or opioid requirementsin women undergoing laparoscopic excision of endometriosis.Methods: Random assignment of 66 women undergoing laparoscopicexcision of endometriosis to receive intra-operative multimodalanalgesia (30 patients) or placebo (36 patients). Analgesia consistedof Diclofenac sodium 100 mg suppository per rectum and 0.75%Ropivacaine to portal sites, sub-peritoneally under excision sites andtopically to each sub-diaphragmatic area. Post-operative in-hospitalanalgesia was standardized for all patients and included IV morphinedelivered by patient controlled analgesia (PCA) in the ward. Theprimary outcome measures were [1] postoperative opioid analgesicrequirements and [2] postoperative pain intensity measured by VisualAnalogue Scale (VAS) and Verbal Descriptor Scale (VDS).Results: There was no difference in baseline variables between thetwo groups. The analgesic group used significantly less morphine inrecovery (0.0 V 8.0 mg; p = 0.016), PCA morphine in the ward (9.0 V21.5 mg; p=0.05), and total hospital opioid (recovery morphine, PCAmorphine and ward breakthrough opioid) (19.0 V 34.5 mg; p = 0.017)compared to the placebo group. Results are presented as medians.There was no difference in post-operative pain intensity between thetwo groups.Conclusions: The use of multimodal intra-operative analgesia atlaparoscopic excision of endometriosis reduces post-operative opioidconsumption.40

SESSION 4References:1. Costello MF, Abbott J, Lenart M, Fawcett S, Vancaille T, Katz S,Wilson S. Analgesia for laparoscopy. Australian GynaecologicalEndoscopy Society “ART and Science” XVth Annual ScientificMeeting Program Book (2005) p22Author address: Dr Michael Costello, School of Women's andChildren's Health, Division of Obstetrics and Gynaecology, RoyalHospital for Women, Barker St, Randwick. NSW. 2031. Tel: 02 – 93826677 Costello MF a,b , Abbott J a,c , Katz S d , Vancaillie T a,c , Lenart M c ,Fawcett S c , Walsh R c , Wilson S d , Lyons S c .aSchool of Women's and Children's Health, Division of Obstetrics andGynaecology, University of NSW, and b Department of ReproductiveMedicine and IVFAustralia, and c Department of Endogynaecology, anddDepartment of Anaesthesia; Royal Hospital for Women, Sydney.Evaluation of early experience with ambulatorygynaecology clinicFriday 18 May / Free Communications 4 / 1410-1420Xu LY, Vivian-Taylor J, Ang WC, Healey MObjective: A preliminary analysis was performed on patients referredto ambulatory gynaecology clinic. The aim was to evaluate the natureand indication for referral, patient characteristics and proceduralsuccess rates. The secondary aim was to identify variables that couldimprove the service.Methods and Materials: The records of patients referred to theambulatory gynaecology list for the preceding 12 months wereevaluated. Data was collected regarding patient characteristics anddemographics, procedural details, success and indication, patientsatisfaction, and histopathology results.Results: The average age of the patients was 44 years. A total of 98patients were referred to ambulatory gynaecology lists. Forty-sixpercent were performed for diagnostic hysteroscopy and sampling.However, this accounted for less than 20% of the general gynaecologythroughput for diagnostic hysteroscopies. Environmental, procedural,personnel and individual factors were identified in the reduced uptakeof ambulatory gynaecology clinics and are discussed.Conclusion: Ambulatory gynaecology offers several advantages to thetraditional inpatient admission. Whilst there were excellent successrates and patient satisfaction, variables have been identified toimprove and expand the service.Keywords: ambulatory, outpatient, hysteroscopyAuthor address: Xu LY, Vivian-Taylor J, Ang WC, Healey M.Gynaecological Endoscopy Unit, Department of Obstetrics &Gynaecology, Royal Women’s Hospital, 132 Grattan St, Carlton,Melbourne, VIC 3053, AustraliaApplying education theory to the informedconsent process using a web-basedmultimedia application – a prospective,randomized, controlled pilot studyFriday 18 May / Free Communications 4 / 1330-1340Claydon-Platt D, Cameron M, Maher P, Ong N,Manwaring J, Beischer AIn Australia, all patients undergoing elective surgery are asked to giveconsent. Legally, prior to gaining consent, there is a requirement of thetreating doctor to disclose all relevant information to patients.Traditionally, information has been given verbally to the patient duringthe medical consultation; however several studies have shown this to befar from adequate for a variety of reasons. While a significant amount ofcurrent research has focused on improving the way in which informationis presented to the patient – there appears to be a paucity of researchlooking at the more fundamental issue of how best to educate patients –which is what we must do before obtaining their informed consent.To do this we looked to contemporary education theory - subsequentlydeveloping an ‘educational module’ and assessment tool for operativelaparoscopy - based on these educational principles. We chose to deliverthis information using an online multimedia program, not only becauseit appears to be the most effective medium for communicatinginformation, but also because it provides patients with the ability toproceed at their own pace, and even review information they findrelevant. This education was delivered as an adjunct to currentstandard consent processes, and is not designed to replace, but ratheraugment the doctor-patient interaction.This ‘educational intervention’ was then delivered online to patientsattending the pre-admission clinic at the Mercy Hospital for Womenand in consultant’s private consulting rooms. Since March 2005, aprospective, randomized, controlled trial has been underway toevaluate this educational intervention. We present the results of thistrial, and discuss the potential applications of such a module in clinicalpractice.Author address: Dr Melissa Cameron. Endosurgery Unit, MercyHospital for Women, 163 Studley Road, Heidelberg VIC 3084.Ph. 03 8458 4901 Email: mcameron@mercy.com.au41RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

FREE COMMUNICATIONSThe informed consent process in a tertiarypublic women’s hospital: are we informing ourpatients (and doctors) and protecting ourselves?Friday 18 May / Free Communications 4 / 1430-1440Cameron M, Maher PThe attainment of a patient’s consent is a legal and ethicalrequirement prior to proceeding with any elective invasive procedure.In recent years, increasing emphasis has been placed on theimportance of informed consent, patient education and documentationof such. Still, great debate exists as to the most effective process bywhich to obtain informed consent, in particular, the breadth ofinformation that should be presented to the patient, and when and bywhom consent should be obtained.As part of a risk management and education planning activity, weundertook an audit of the consent process for operative laparoscopiesin a tertiary public women’s hospital in Melbourne, Australia. Allgynaecology medical staff (ranging from junior resident medical staffwith little or no operative gynaecology experience, to seniorconsultants) were encouraged to participate in the audit.The results of the audit will be presented including data regarding whois obtaining consent, the nature of the discussions regarding consentand the accompanying documentation. Future plans for introduction ofa standardised, web-based, patient education model will be discussed.Author address: Dr Melissa Cameron. Endosurgery Unit, MercyHospital for Women, 163 Studley Road, Heidelberg VIC 3084 Ph. 038458 4901 Email: mcameron@mercy.com.auAGES 2007 XVII ANNUAL SCIENTIFIC MEETING42

EXHIBITORSPlatinum Sponsor of AGESStryker is a global leader in medical devices that develops,manufactures and markets speciality surgical and medicalproducts. Stryker has a strong focus on product innovation thatassists surgeons and health care providers to restore active lifefor the patient.Stryker Endoscopy is the technology leader in minimallyinvasive surgery in today's advanced, and rapidly changing,operation room environments. Our innovative products help givesurgeons more control and patients better outcomes - whilemaking surgery easier and more efficient for medicalprofessionals and hospital administrators.Stryker Communications connects surgeons and other medicalprofessionals with the information they need using our i-Suitetechnology. Our systems link operating rooms with facilitiesaround the world - supporting them with a range of integratedsurgical equipment, lights and booms. These systems exchangeMRIs, X-rays, live pictures and other kinds of informationbetween operating rooms, doctors' offices and teachinginstitutions everywhere. Our goal is to make telemedicine areality, in real time, with worldwide access.Stryker Instruments is a leader in creating products that makesurgery more efficient, reduce trauma and improve techniques.We are known for a wide range of innovative operating roomproducts, from our leading power tools to advanced systems forirrigation, personal protection and pain management.StrykerUnit 58, 2A Herbert Street,St Leonards NSW 2065Tel: (02) 9467 1000 Fax: (02) 9467 1010Website: www.stryker.com43RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

EXHIBITORSMajor Sponsor of AGESJohnson & Johnson, through its operating companies, is theworld's most comprehensive and broadly based manufacturer ofhealth care products, as well as a provider of related services,for the consumer, pharmaceutical, and medical devices anddiagnostics markets. The more than 200 Johnson & Johnsonoperating companies employ approximately 110,000 men andwomen in 57 countries and sell products throughout the world.The fundamental objective of Johnson & Johnson is to providescientifically sound, high quality products and services to helpheal, cure disease and improve the quality of life. This is a goalthat began with the Company's founding in 1886.Johnson & Johnson Medical Australia and New Zealand has along commitment to the Gynaecological community via its’Gynecare, ETHICON and ETHICON ENDO-SURGERY companies.Our investment in minimally invasive surgery began in Australiain the early 1990’s and has been responsible for thedevelopment of product brands such as Endopath® XCELTrocars the Harmonic ACE, Gynecare Prolift Pelvic FloorRepair Systems and Gynecare TVT devices. In 2007 weproudly introduce the Gynecare TVT SECUR System forminimally invasive treatment of incontinence.AGES 2007 XVII ANNUAL SCIENTIFIC MEETINGJohnson & Johnson Medical. Committed to Minimally InvasiveGynaecological SurgeryJohnson & Johnson Medical PTY LTD1-5 Khartoum Rd,North Ryde,NSW 2113,Australia02 9878900044

EXHIBITORSMajor Sponsors of AGES 2007'Excellence in laparoscopic surgery begins with an image'.As leaders in imaging technology and electrosurgical devices,ConMed Linvatec is displaying the latest in Electrosurgical andEndosurgical innovations:We hope you can visit our trade stand and gain someinformation on some of our products on display, namely – IVSTunneller; AutoSuture Endo GIA Universal; Endo Catch Gold;McCartney Tube; Versastep; Versaport V2 Ribbed Trocar;Valleylab Ligaure V and Synetrue Caprosyn.Visit us on stand number 3.ConMed Endosurgery offers a complete range of disposable andreposable devices from access through to closure.The Vcare® Uterine Elevator Retractor offers manyadvantages, it:• surrounds the cervix, defining colpotomy;• displaces the cervix away from the ureters;• retracts the urinary bladder;• compresses the uterine vessels;Tyco Healthcare Australia• prevents loss of the pneumoperitoneum during colpotomy.Contact: Jacqui O’BrienPostal Address: 166 Epping Road LANE COVE NSW 2066Telephone: (02) 9418 9611Facsimile: (02) 9418 9622Web Address: www.tycohealthcare.com.auConMed LinvatecUnit 4, No 10Rodborough RoadFrench ForestNSW 2086Ros Frizell Phone: 1800 238 238Fax: 1800 238 29845 RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

EXHIBITORSApplied MedicalAmerican Medical SystemsAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGApplied Medical designs, manufactures and distributes specializedsurgical devices that enhance clinical outcomes at affordable prices.We focus on innovation in the fields of general, colorectal, urological,obstetrics & gynecological, cardiac and vascular surgery.As a New Generation Medical Company, Applied Medical’s mission isto improve the quality, availability and affordability of healthcare bydriving sustainable, progressive solutions in products, practices andprocedures.Please visit us at booth number 13 or contact Applied Medical –Customer Relations, Ph: 1800 666 272 or (07) 3853 2100 or visit us onour website: www.appliedmedical.comB BraunB. Braun – Sharing Expertise. In dialogue with the people who use thecompany’s products, B. Braun is continually gaining new knowledge andincorporating it into product development. In this way, the companycontributes with innovative products and services towards optimizingworking procedures in hospitals and medical practices all over the worldand improving safety – for patients, doctors and nursing staff.B. Braun Australia,17 Lexington Drive, BELLA VISTA NSW 2153Contact: Jane Markey (Product Manager - Endosurgery)Mobile: 0408 663 946Customer Service: 1800 251 705CytycCytyc Corporation is a diagnostic and medical device company thatdesigns, develops and manufactures innovative and clinically effectivediagnostic and surgical products. Cytyc's products include cervicalcancer screening (ThinPrep® Pap Test), preterm birth screening(FullTerm®), treatment of excessive menstrual bleeding (NovaSure®),radiation treatment of early-stage breast cancer (MammoSite®).Cytyc (Australia) Pty Ltd – Ph: 1800 264 073Gyrus ACMIIn 2005 Gyrus Group PLC acquired ACMI, (American CystoscopeMakers Inc), a company with a 100 year history in Endoscopicsurgical devices.The new entity- Gyrus ACMI is a market leader in tissuemanagement and visualisation technologies, across a range ofsurgical specialties including ENT, Urology, Gynaecology andGeneral Surgery.American Medical Systems is a trusted leader in providing medicalsolutions that restore the pelvic health of men and women worldwide.AMS Australia- Level 2, 460 Church St, North Parramatta, NSW 2151.02 8838 8800Fisher & PaykelFisher & Paykel Healthcare is a leading designer, manufacturer andmarketer of heated humidification products and systems for use inrespiratory care and the treatment of obstructive sleep apnea. It alsooffers an innovative range of neonatal care products.More recently Fisher & Paykel Healthcare has taken and adaptedexisting technology from our Respiratory Humidifier producing a devicewhich Heats and Humidifies CO2 for use in Endoscopic Surgery. Thebenefits being, reduced post operative pain, reduced recovery time,reduction in adhesions and improved scope clarity. The company’sproducts are sold in over 110 countries worldwide.Address: 36-40 New Street, Ringwood, VIC 3134 with our head officeHead Office: 15 Maurice Paykel Place, East Tamaki, New Zealand.Ph: 03 9879 5022N Stenning174 Parramatta Road CAMPERDOWN NSW 2050Ph: (02) 8594-9100 / Fax: (02) 8594-9199http://www.nstenning.com.auWe are proud to support the 2007 AGES Annual Scientific Meeting.Please visit our display to see:From Karl StorzRotocut GI – The new electronic MorcellatorA complete range of Laparoscopic and HysteroscopicEndoscopes and accessoriesEssure from Conceptus, providing permanent birth controland an alternative to incisionWeck Hem-O-Lok ClipsOlympusOlympus Australia PTY LTD was established in June 1997 as a directsubsidiary of the Olympus Corporation Japan. The release of theEXERA II, a new High Definition imaging platform is compatible withover 200 endoscopic videoscopes and surgical camera heads,answering both your endoscopic and surgical needs. Olympus alsooffers a quality German manufactured telescope and instrument rangesaddressing the need of surgical specialties.Nadine Winkelmann, Product Manager – Theatre Products03 9265 5442 / 0418 375 35046

LIST OF EXHIBITORSAmerican Medical SystemsApplied MedicalB Braun AustraliaBard AustraliaBoston ScientificConMed LinvatecCook AustraliaCytycDevice TechnologiesEndocorpExperienFisher & PaykelGyrus ACMIGytechInSight OceaniaJohnson & JohnsonMedfinN StenningNoall & Co.OlympusStrykerSydmed AustraliaSydney IVFSymbion Laverty Pathologytyco Healthcare47 RISK MANAGEMENT IN GYNAECOLOGY AND ENDOSCOPIC SURGERY

AGES MEMBERSHIPYour Details:Payment detailsTITLEFIRST NAMECOMPANYSURNAMEPayment by chequePlease send membership form and cheque made payable to “AGES “ to:Conference Connection282 Edinburgh RoadCastlecrag, NSW 2068ADDRESSPayment by credit card(Visa or Mastercard only)CITY STATE POSTCODECOUNTRY| ___ ___ ___ ___ | ___ ___ ___ ___ | ___ ___ ___ ___ | ___ ___ ___ ___ |Card NumberExpiry DatePHONEMOBILEFACSIMILEE-MAILCardholder NameSignaturePROPOSERSECONDERDateDescriptionAGES 2007 XVII ANNUAL SCIENTIFIC MEETINGMembership subscription to the Australian Gynaecological EndoscopySociety for period:1 January 2007 to 31 December 2007Please tick the appropriate membershipFellow $325 Overseas Fellow AU$295Registrar/Trainee FREE IN 2007 † AAGL Journal $120Preferred website password: | __ | __ | __ | __ | __ | __ | __ | __ |(up to 8 alphanumeric characters)† Application necessary. Membership excludes AAGL Journal48

MEMBERSHIP OF AGESmore than endoscopic surgeryAGES at its scientific meetings considers all aspects of gynaecological surgery.The successful AGES Pelvic Floor Group has provided a benchmark forum forgynaecologists predominantly interested in vaginal and reconstructive surgery.keep informedThrough its conferences, forums and publications, the Australian GynaecologicalEndoscopy Society (AGES) constantly updates members’ knowledge andexpertise.save moneyAs a member of the Society, you will receive discounts on fees for AGESScientific Meetings as well as receiving the American Association ofGynecologic Laparoscopists Journal and AGES’ newsletter, SCOPE, free ofcharge. The AAGL Journal is normally available at US$175 [in excess ofAU$210*]*Based on exchange rates at time of printing.do research$300,000 is available to AGES members over three years from 2005 for researchinto Gynaecological Surgery and the improvement of women’s health.earn PR&CRM pointsAt AGES Scientific Meetings, delegates earn PR&CRM points, in addition toCPD points.better educationOne of the ongoing principal roles of AGES will be in education.The AGES Education Subcommittee has been extremely active in helping theCollege to improve laparoscopic surgical training.objectives• To encourage high standards of Gynaecological Surgery• To provide a forum for discussion and innovation in all aspects ofGynaecological Surgery• To organise scientific meetings for the exchange of knowledgeand expertise• To provide a network of experienced Gynaecological Endoscopic Surgeons tooptimise patient care and facilitate liaison with other health professionals• To encourage scientific research and publications on Gynaecological andEndoscopic Surgery• To acknowledge individuals who have made outstanding contributions to thefield of Gynaecological Endoscopy• To provide opportunities for training in Gynaecological Endoscopy byorganising workshops and training coursesmembership benefits• Discounted registration fees at all AGES Scientific Meetings †• Free subscription to the American Association of GynecologicalLaparoscopists’ Journal, a dedicated and highly respectedendoscopic journal †• Free AGES newsletter, SCOPE, published three times annually• Member access to AGES website (www.ages.com.au)• Free listing in the Membership Directory of the AGES website• Scholarships are awarded to AGES members to enhance their skills• Dissemination of clinical updates on a regular basis• Eligibility to apply for AGES Research GrantsAGES Clinical Research FundAGES also supports research into Endoscopic and Gynaecological Surgery. AClinical Research Fund has been established by AGES as a result of a significantfunding commitment from Stryker. AGES is also investing in this fund so that$300,000 is available to AGES members over three years from 2005 for researchinto Gynaecological Surgery and the improvement of women’s health.Annual Membership Fee:Fellows AU$325 including gstRegistrar/Trainee FREE IN 2007 Application required and excluding AAGL JournalOverseas Fellows AU$295Membership Application Forms are available from:www.ages.com.auorAGES Secretariat282 Edinburgh RoadCASTLECRAG NSW 2068AUSTRALIA†Only available with paid membershipsMELBOURNE AUSTRALIA11-14 MARCH 200810THWORLD CONGRESSON ENDOMETRIOSISOur vision:The energy of AGES in Surgery, Science and Patient Care inthe 21st Century.Our theme:ART AND SCIENCE OF ENDOMETRIOSISClinical acumen, surgical flare and biomedical advancesunite to engage endometriosis: do not miss this event!Program and registration availableat www.wce2008.comAGES President: Dr Rob O’SheaOrganiser: Mrs Michele BenderChairman: Prof. David HealyPlatinum SponsorWorldEndometriosisSocietyAustralianGynaecologicalEndoscopySocietyArtwork: Fiona Hall born Australia 1953 | Paradisus Terrestris Entitled: Miwulngini (Ngan’gikurunggurr) / Nelumbo nucifera / lotus (1996) | aluminium and tin 24.6 x 12.1 x 3.6 cm | Purchased through The Art Foundationof Victoria with the assistance of the Rudy Komon Fund, Governor, 1997 | National Gallery of Victoria, Melbourne. | Fiona Hall is a leading Australian contemporary artist with a formidable career spanning three decades.

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